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Murea M, Raimann JG, Divers J, Maute H, Kovach C, Abdel-Rahman EM, Awad AS, Flythe JE, Gautam SC, Niyyar VD, Roberts GV, Jefferson NM, Shahidul I, Nwaozuru U, Foley KL, Trembath EJ, Rosales ML, Fletcher AJ, Hiba SI, Huml A, Knicely DH, Hasan I, Makadia B, Gaurav R, Lea J, Conway PT, Daugirdas JT, Kotanko P. Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial). Trials 2024; 25:424. [PMID: 38943204 PMCID: PMC11212207 DOI: 10.1186/s13063-024-08281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients. METHODS An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients). DISCUSSION Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers. TRIAL REGISTRATION Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA.
| | | | - Jasmin Divers
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Harvey Maute
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Emaad M Abdel-Rahman
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Alaa S Awad
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Samir C Gautam
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Vandana D Niyyar
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Glenda V Roberts
- External Relations and Patient Engagement, Division of Nephrology, Department of Medicine, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, WA, USA
| | | | - Islam Shahidul
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Sheikh I Hiba
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Anne Huml
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Daphne H Knicely
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Irtiza Hasan
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | | | - Raman Gaurav
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Janice Lea
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Paul T Conway
- American Association of Kidney Patients, Tampa, FL, USA
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Peter Kotanko
- Department of Internal Medicine, Section on Nephrology, LLC Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Lee S, Pham NM, Montez-Rath ME, Bolanos CG, Bonde SS, Meyer TW, Sirich TL. Twice Weekly versus Thrice Weekly Hemodialysis-A Pilot Cross-Over Equivalence Trial. Clin J Am Soc Nephrol 2024:01277230-990000000-00417. [PMID: 38922689 DOI: 10.2215/cjn.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
Key Points
The 2015 Kidney Disease Outcomes Quality Initiative Guideline Update increased the contribution of residual kidney function, shortening the time required for twice weekly hemodialysis.No study had yet assessed the feasibility of prescribing twice weekly hemodialysis according to the updated guideline.Twice weekly hemodialysis prescribed using the updated guideline maintained quality of life and controlled fluid gain, potassium, and uremic solutes.
Background
The 2015 Update of the Kidney Disease Outcomes Quality Initiative (KDOQI) Guideline for Hemodialysis Adequacy increased the contribution of residual kidney function in calculating standard Kt/Vurea (stdKt/Vurea). However, no study has assessed the effect of prescribing twice weekly hemodialysis according to this guideline on patients' quality of life or uremic solute levels.
Methods
Twenty six hemodialysis patients with average residual urea clearance (Kru) 4.7±1.8 ml/min and hemodialysis vintage of 12±15 months (range 2 months to 4.9 years) underwent a cross-over trial comparing four weeks of twice weekly hemodialysis and four weeks of thrice weekly hemodialysis. Twice weekly hemodialysis was prescribed to achieve stdKt/Vurea 2.2 incorporating Kru using the 2015 KDOQI Guideline. Thrice weekly hemodialysis was prescribed to achieve spKt/Vurea 1.3 regardless of Kru. Quality of life and plasma levels of secreted uremic solutes and β
2 microglobulin were assessed at the end of each period.
Results
Equivalence testing between twice and thrice weekly hemodialysis based on the Kidney Disease Quality of Life instrument (primary analysis) was inconclusive. Symptoms as assessed by the secondary outcomes Dialysis Symptom Index and Post-Dialysis Recovery Time were not worse with twice weekly hemodialysis. StdKt/Vurea was adequate during twice weekly hemodialysis (2.7±0.5), and ultrafiltration rate and plasma potassium were controlled with minimally longer treatment times (twice weekly: 195±20 versus thrice weekly: 191±17 minutes). Plasma levels of the secreted solutes and β
2 microglobulin were not higher with twice weekly than thrice weekly hemodialysis.
Conclusions
Twice weekly hemodialysis can be prescribed using the higher contribution assigned to Kru by the 2015 KDOQI Guideline. With twice weekly hemodialysis, quality of life was unchanged, and the continuous function of the residual kidneys controlled fluid gain and plasma levels of potassium and uremic solutes without substantially longer treatment times.
Clinical Trial registration number:
NCT03874117.
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Affiliation(s)
- Seolhyun Lee
- The Departments of Medicine, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California
| | - Nhat M Pham
- The Department of Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Maria E Montez-Rath
- The Departments of Medicine, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California
| | - Christian G Bolanos
- The Departments of Medicine, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California
| | - Saniya S Bonde
- The Departments of Medicine, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California
| | - Timothy W Meyer
- The Departments of Medicine, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California
| | - Tammy L Sirich
- The Departments of Medicine, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California
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3
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Fernández Lucas M, Piris González M, Díaz Domínguez ME, Collado Alsina A, Rodríguez Mendiola NM. Incremental hemodialysis and vascular access complications: a 12-year experience in a hospital hemodialysis unit. J Nephrol 2024:10.1007/s40620-024-01932-9. [PMID: 38837005 DOI: 10.1007/s40620-024-01932-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/09/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Incremental hemodialysis (HD) is considered a valid alternative for patients with residual kidney function. Evidence concerning its effect on vascular access is scarce. We present our 12-year experience of an incremental hemodialysis program with the aim of evaluating survival and complications of arteriovenous fistula in these patients compared to the thrice-weekly scheme. METHODS From January 1st, 2006 to December 31st, 2017, 220 incident patients started hemodialysis, 132 (60%) of whom began hemodialysis with two sessions per week and 88 (40%) with three sessions per week. Demographic and clinical variables were assessed at the start of treatment. Data regarding arteriovenous fistula survival and complications were collected. RESULTS Both groups had similar baseline sociodemographic and clinical characteristics. A total of 188 (85%) patients were dialyzed with an arteriovenous fistula during follow-up. Eighty-three patients had one or more fistula complications, with no differences between incremental and conventional groups (p = 0.55). Fistula survival rates showed no significant difference between the two groups, whether analyzed from the date of fistula creation (Log Rank p = 0.810) or from the date of initial fistula cannulation (Log Rank p = 0.695). CONCLUSIONS We found no differences in arteriovenous fistula survival or complication rate between patients who started HD with an incremental versus a conventional treatment scheme. Randomized controlled clinical trials may be warranted to achieve a higher degree of evidence.
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Affiliation(s)
- Milagros Fernández Lucas
- Nephrology Department, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.
- Alcalá de Henares University, Madrid, Spain.
| | - Marcos Piris González
- Nephrology Department, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Martha Elizabeth Díaz Domínguez
- Nephrology Department, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Andrea Collado Alsina
- Nephrology Department, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Nuria María Rodríguez Mendiola
- Nephrology Department, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
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Sirich TL, Tan Z, Highland BR, Lin Z, Russell GB, Murea M. Longitudinal Changes in Kidney Solute Clearance in a Prospective Cohort of Patients Initiating Chronic Hemodialysis. Kidney Int Rep 2024; 9:1774-1782. [PMID: 38899221 PMCID: PMC11184396 DOI: 10.1016/j.ekir.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Longitudinal changes in residual kidney function have not been well-examined in patients starting chronic hemodialysis (HD). Methods We analyzed urine volume and kidney solute clearances from timed urine collections and corresponding plasma samples from 42 patients randomized to incremental HD (n = 21) and conventional HD (n = 21) in the TwoPlus pilot study. Samples were collected before HD initiation (baseline); and at 6, 12, 24, and 48 weeks. We assessed temporal trends in urine volume, kidney urea and creatinine clearance, and correlations between urine volume and kidney solute clearance. Results Residual kidney function parameters in all patients declined over time; the pattern of decline differed between urine volume and kidney solute clearances. Urine volume declined at a steady rate with median (quartile 1, quartile 3) percentage change relative to baseline of -10% (-36 to 29) at week 6 and -47% (-76 to 5) by week 48. Kidney urea and creatinine clearances exhibited a larger decline than urine volume at week 6, -32% (-61 to 8) and -47% (-57 to -20), respectively. The rate of decline subsequently slowed, reaching about 61% decline for both solutes by week 48. Conventional HD demonstrated larger declines in urine volume and kidney urea clearance than incremental HD at week 6. Urine volume showed moderate correlation with urea (R = 0.47) and weaker correlation with creatinine (R = 0.34). Conclusion Despite gradual decrement in urine volume and kidney solute clearances, residual kidney function persists nearly 1 year after HD initiation. This knowledge could motivate increased practice of individualizing HD prescriptions by incorporating residual kidney function.
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Affiliation(s)
- Tammy L. Sirich
- Department of Medicine, Stanford University, Palo Alto, California, USA
- Department of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Zijian Tan
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Benjamin R. Highland
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Zhidong Lin
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory B. Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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5
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Butt U, Davenport A, Sridharan S, Farrington K, Vilar E. A practical approach to implementing incremental haemodialysis. J Nephrol 2024:10.1007/s40620-024-01939-2. [PMID: 38763995 DOI: 10.1007/s40620-024-01939-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/24/2024] [Indexed: 05/21/2024]
Abstract
The majority of end-stage kidney disease patients are treated with haemodialysis (HD). Starting HD can pose physical, social, and psychological challenges to patients, and mortality rates within the first 6 months are disproportionately high, with intensive HD regimens implicated as a potential factor. Starting HD with an incremental approach, taking residual kidney function (RKF) into account, potentially allows for a gentle start with reduced dialysis intensity. Dialysis intensity (session time or frequency) can then be proportionally increased as RKF reduces. This approach to starting HD has been reported in observational studies to result in better patient self-reported health quality of life and reduced costs, and now several definitive randomised controlled trials are underway comparing an incremental approach to the conventional thrice weekly paradigm. Physician concerns over the risk of inadequate dialysis, with consequent increased emergency admissions, and practical challenges of how to estimate RKF and implement incremental dialysis have impeded widespread adoption. Addressing these challenges is paramount to increasing the uptake of incremental HD. Careful patient selection lies at the heart of a successful incremental HD programme. Generally, patients with a residual urea clearance of > 3 ml/min/1.73 m2 can be considered suitable for starting with incremental HD provided they comply with fluid intake, salt and other dietary recommendations. Calculating RKF from regular interdialytic urine collections and appropriately adjusting sessional HD clearance targets are practical and conceptual challenges. In this report we aim to disentangle these complexities and provide a step-by-step guide for patient selection and adjusting dialysis sessional targets.
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Affiliation(s)
- Usama Butt
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK.
| | - A Davenport
- Royal Free Hospital, Royal Free London Foundation Trust, London, UK
- University College London, London, UK
| | - S Sridharan
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
| | - K Farrington
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
| | - E Vilar
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
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Casino DFG, Murea M, Floege MJ, Zoccali C. Incremental dialysis: two complementary views. Clin Kidney J 2024; 17:sfae020. [PMID: 38404364 PMCID: PMC10894032 DOI: 10.1093/ckj/sfae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Indexed: 02/27/2024] Open
Abstract
Franco Casino and Mariana Murea discuss today's knowledge about the 'incremental dialysis' concept. Franco Casino frames the problem by saying that, in the presence of substantial residual kidney function, kidney replacement therapy can begin with low doses and/or frequencies, to be gradually increased to compensate for any subsequent losses of residual kidney function, keeping the total clearance above the minimum levels of adequacy. He remarks that studies so far have documented that this approach is safe. He recognizes that adequate randomized controlled trials (RCTs) are necessary to confirm the safety and simplify and standardize the practical aspects of this approach. Mariana Murea objects that most of the evidence gathered so far primarily derives from retrospective and observational studies, which can be influenced by socioeconomic constraints. She argues for the need for RCTs to provide compelling empirical evidence on the efficacy of incremental dialysis. Nephrologists are still reluctant to adopt this approach for various reasons, including unfamiliarity with the method, lack of practical guidance and financial disincentives. Several countries have ongoing or planned RCTs comparing incremental dialysis with conventional dialysis. These trials can shift the haemodialysis paradigm if they validate the safety and effectiveness of this approach. The moderators believe that the results of ongoing trials must be carefully interpreted, and further validation may be needed across different patient populations or healthcare settings. The ultimate goal is to gather robust evidence that could lead to widespread adoption of incremental haemodialysis, optimizing treatment, reducing overtreatment, preserving resources and improving patients' quality of life.
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Affiliation(s)
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Carmine Zoccali
- Renal Research Institute NY, USA
- BIOGEM, Ariano Irpino, Italy
- IPNET, Reggio Cal, Italy
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Munshi R, Swartz SJ. Incremental dialysis: review of the literature with pediatric perspective. Pediatr Nephrol 2024; 39:49-55. [PMID: 37306719 DOI: 10.1007/s00467-023-06030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/24/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023]
Abstract
Drivers towards initiation of kidney replacement therapy in advanced chronic kidney disease include metabolic and fluid derangements, growth, and nutritional status with focus on health optimization. Once initiated, prescription of dialysis is often uniform despite variability in patient characteristics and etiology of kidney failure. Preservation of residual kidney function has been associated with improved outcomes in patients with advanced chronic kidney disease on dialysis. Incremental dialysis is the approach of reducing the dialysis dose by reduction in treatment time, days, or efficiency of clearance. Incremental dialysis has been described in adults at initiation of kidney replacement therapy, to better preserve residual kidney function and meet the individual needs of the patient. Consideration of incremental dialysis in pediatrics may be reasonable in a subset of children with continued emphasis on promotion of growth and development.
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Affiliation(s)
- Raj Munshi
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's, University of Washington, Seattle, WA, USA.
| | - Sarah J Swartz
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Takkavatakarn K, Jintanapramote K, Phannajit J, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Incremental versus conventional haemodialysis in end-stage kidney disease: a systematic review and meta-analysis. Clin Kidney J 2024; 17:sfad280. [PMID: 38186889 PMCID: PMC10768771 DOI: 10.1093/ckj/sfad280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Indexed: 01/09/2024] Open
Abstract
Background Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice-weekly haemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD compared with conventional HD were explored in this systematic review and meta-analysis. Methods We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization and mortality. Results A total of 36 articles (138 939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD {odds ratio [OR] 0.87 [95% confidence interval (CI)] 0.72-1.04 and OR 0.67 [95% CI 0.43-1.05], respectively}. However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD [OR 0.44 (95% CI 0.27-0.72) and OR 0.31 (95% CI 0.25-0.39), respectively]. In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events [OR 0.22 (95% CI 0.08-0.63)] and mortality [OR 0.54 (95% CI 0.37-0.79)]. Vascular access complications, hyperkalaemia and volume overload were not statistically different between groups. Conclusions Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.
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Affiliation(s)
- Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kavita Jintanapramote
- Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Royal Thai Air Force, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Research Unit for Metabolic Bone Disease in CKD patients, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Research Unit for Metabolic Bone Disease in CKD patients, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Okazaki M, Obi Y, Shafi T, Rhee CM, Kovesdy CP, Kalantar-Zadeh K. Residual Kidney Function and Cause-Specific Mortality Among Incident Hemodialysis Patients. Kidney Int Rep 2023; 8:1989-2000. [PMID: 37849997 PMCID: PMC10577493 DOI: 10.1016/j.ekir.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/16/2023] [Accepted: 07/24/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction The survival benefit of residual kidney function (RKF) in patients on hemodialysis is presumably due to enhanced fluid management and solute clearance. However, data are lacking on the association of renal urea clearance (CLurea) with specific causes of death. Methods We conducted a longitudinal cohort study of 39,623 adults initiating thrice-weekly in-center hemodialysis from 2007 to 2011 and had data on renal CLurea and urine volume. Multivariable cause-specific proportional hazards model was used to examine the associations between baseline RKF and cause-specific mortality, including sudden cardiac death (SCD), non-SCD cardiovascular death (CVD), and non-CVD. Restricted cubic splines were fitted for change in RKF over 6 months after initiating hemodialysis. Results Among 39,623 patients with data on baseline renal CLurea and urine volume, there was a significant trend toward a higher mortality risk across lower RKF levels, irrespective of cause of death in a case-mix adjustment model (Ptrend < 0.05). Adjustment for ultrafiltration rate (UFR) slightly attenuated the association between low renal CLurea and high cause-specific mortality, whereas adjustment for highest potassium did not have substantial effect. Among 12,169 patients with data on change in RKF, a 6-month decline in renal CLurea showed graded associations with SCD, non-SCD CVD, and non-CVD risk, whereas the graded associations between faster 6-month decline in urine output and higher death risk were clear only for SCD and non-CVD. Conclusion Lower RKF and loss of RKF were associated with higher cause-specific mortality among patients initiating thrice-weekly in-center hemodialysis.
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Affiliation(s)
- Masaki Okazaki
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Tariq Shafi
- Division of Nephrology, Houston Methodist Hospital, Houston, Texas, USA
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine Medical Center, Orange, California, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
- Los Angeles County Harbor-UCLA Medical Center, and The Lundquist Institute, Torrance, California, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
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10
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Evgenia G, Yafa F, Hadas A, Shelly L, Amit D, Landau D, Orly H. Incremental hemodialysis in pediatric patients. J Nephrol 2023:10.1007/s40620-023-01668-y. [PMID: 37341967 DOI: 10.1007/s40620-023-01668-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/29/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Incremental hemodialysis follows the concept of adjusting dialysis dose according to residual kidney function. Data on incremental hemodialysis in pediatric patients is lacking. METHODS We conducted a retrospective analysis of children initiating hemodialysis between January 2015 and July 2020 in a single tertiary center, comparing the characteristics and outcomes of those who commenced with incremental hemodialysis vs with conventional thrice-weekly regimen. RESULTS Data on forty patients, 15 (37.5%) on incremental hemodialysis and 25 (63%) on thrice-weekly hemodialysis were analyzed. No differences in age, estimated glomerular filtration rate and metabolic parameters were noted between groups at baseline, but there were more males (73 vs 40%, p = 0.04), more patients with congenital anomalies of kidney and urinary tract (60 vs 20%, p = 0.01), higher urine output (2.5 ± 1 vs 1 ± 0.8 ml/kg/h, p < 0.001), lower use of antihypertensive medications (20 vs 72%, p = 0.002) and lower prevalence of left ventricular hypertrophy (6.7 vs 32%, p = 0.003) in the incremental hemodialysis group vs thrice-weekly hemodialysis. During follow up, 5 (33%) incremental hemodialysis patients were transplanted, 1 (7%) remained on incremental hemodialysis at 24 months, and 9 (60%) transitioned to thrice-weekly hemodialysis at a median (IQR) time of 8.7 (4.2, 11.8) months. At last follow up, fewer patients who initiated incremental hemodialysis had left ventricular hypertrophy (0 vs 32%, p = 0.016) and urine output < 100 ml/24 h (20 vs 60%, p = 0.02) compared to thrice-weekly hemodialysis, with no significant differences in metabolic or growth parameters. CONCLUSION Incremental hemodialysis is a viable option for initiating dialysis in selected pediatric patients, that may help improve patients' quality of life and reduce dialysis burden without compromising clinical outcome.
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Affiliation(s)
- Gurevich Evgenia
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel
- Department of Pediatrics, Barzilai Medical Center, Ashkelon, Israel
- Department of Pediatrics, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Falush Yafa
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel
| | - Alfandari Hadas
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Levi Shelly
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel
| | - Dagan Amit
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Landau
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haskin Orly
- Institute of Nephrology, Schneider Children's Medical Center of Israel, 14 Kaplan St, 4920235, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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11
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Murea M, Lin E, Torreggiani M. On the path to individualizing care with incremental-start hemodialysis. J Nephrol 2023:10.1007/s40620-023-01689-7. [PMID: 37289367 DOI: 10.1007/s40620-023-01689-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - Eugene Lin
- Department of Medicine, Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037, Le Mans, France.
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12
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Hegerty K, Jaure A, Scholes-Robertson N, Howard K, Ju A, Evangelidis N, Wolley M, Baumgart A, Johnson DW, Hawley CM, Reidlinger D, Hickey L, Welch A, Cho Y, Kerr PG, Roberts MA, Shen JI, Craig J, Krishnasamy R, Viecelli AK. Australian Workshops on Patients' Perspectives on Hemodialysis and Incremental Start. Kidney Int Rep 2023; 8:478-488. [PMID: 36938090 PMCID: PMC10014336 DOI: 10.1016/j.ekir.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Most patients with kidney failure commence and continue hemodialysis (HD) thrice weekly. Incremental initiation (defined as HD less than thrice weekly) is increasingly considered to be safe and less burdensome, but little is known about patients' perspectives. We aimed to describe patients' priorities and concerns regarding incremental HD. Methods Patients currently, previously, or soon to be receiving HD in Australia participated in two 90-minute online workshops to discuss views about HD focusing on incremental start and priorities for trial outcomes. Transcripts were analyzed using thematic analysis. Outcomes were ranked on the basis of the sum of participants' priority scores (i.e., single allocation of 3 points for most important, 2 for second, and 1 for third most important outcome). Results All 26 participants (1 caregiver and 25 patients) preferred an incremental HD approach. The top prioritized outcomes were quality of life (QOL) (56 points), residual kidney function (RKF) (27 points), and mortality (16 points). The following 4 themes underpinning outcome priorities, experience, and safety concerns were identified: (i) unpreparedness and pressure to adapt, (ii) disruption to daily living, (iii) threats to safety, and (iv) hope and future planning. Conclusion Patients with kidney failure preferred an incremental start to HD to minimize disruption to daily living and reduce the negative impacts on their education, ability to work, and family life. QOL was the most critically important outcome, followed by RKF and survival.
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Affiliation(s)
- Katharine Hegerty
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Correspondence: Katharine Hegerty, Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland, 4102, Australia.
| | - Allison Jaure
- The University of Sydney, New South Wales, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, New South Wales, Australia
| | - Nicole Scholes-Robertson
- The University of Sydney, New South Wales, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, New South Wales, Australia
| | - Kirsten Howard
- Menzies Center for Health Policy and Economics, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Angela Ju
- The University of Sydney, New South Wales, Australia
| | - Nicole Evangelidis
- The University of Sydney, New South Wales, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, New South Wales, Australia
| | - Martin Wolley
- Royal Brisbane and Women’s Hospital, Queensland, Australia
| | | | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Laura Hickey
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Alyssa Welch
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Matthew A. Roberts
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jenny I. Shen
- Division of Nephrology and Hypertension, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jonathan Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rathika Krishnasamy
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Department of Nephrology, Sunshine Coast University Hospital, Queensland, Australia
| | - Andrea K. Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
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13
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Murea M, Kalantar-Zadeh K. Starting chronic hemodialysis twice weekly: when less is more. Nephrol Dial Transplant 2022; 37:2297-2299. [PMID: 36083981 DOI: 10.1093/ndt/gfac261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Indexed: 12/31/2022] Open
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA.,Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA.,Dept Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA.,The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
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14
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Murea M, Highland BR, Yang W, Dressler E, Russell GB. Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis. BMC Nephrol 2022; 23:322. [PMID: 36167537 PMCID: PMC9513956 DOI: 10.1186/s12882-022-02946-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden. Methods The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group). Results The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD. Conclusions This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations. Trial registration Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02946-w.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - Benjamin R Highland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wesley Yang
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emily Dressler
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
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15
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Groth T, Stegmayr BG, Ash SR, Kuchinka J, Wieringa FP, Fissell WH, Roy S. Wearable and implantable artificial kidney devices for end-stage kidney disease treatment-Current status and review. Artif Organs 2022; 47:649-666. [PMID: 36129158 DOI: 10.1111/aor.14396] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a major cause of early death worldwide. By 2030, 14.5 million people will have end-stage kidney disease (ESKD, or CKD stage 5), yet only 5.4 million will receive kidney replacement therapy (KRT) due to economic, social, and political factors. Even for those who are offered KRT by various means of dialysis, the life expectancy remains far too low. OBSERVATION Researchers from different fields of artificial organs collaborate to overcome the challenges of creating products such as Wearable and/or Implantable Artificial Kidneys capable of providing long-term effective physiologic kidney functions such as removal of uremic toxins, electrolyte homeostasis, and fluid regulation. A focus should be to develop easily accessible, safe, and inexpensive KRT options that enable a good quality of life and will also be available for patients in less-developed regions of the world. CONCLUSIONS Hence, it is required to discuss some of the limits and burdens of transplantation and different techniques of dialysis, including those performed at home. Furthermore, hurdles must be considered and overcome to develop wearable and implantable artificial kidney devices that can help to improve the quality of life and life expectancy of patients with CKD.
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Affiliation(s)
- Thomas Groth
- Department Biomedical Materials, Institute of Pharmacy, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,International Federation for Artificial Organs, Painesville, Ohio, USA
| | - Bernd G Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
| | | | - Janna Kuchinka
- Department Biomedical Materials, Institute of Pharmacy, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Fokko P Wieringa
- IMEC, Eindhoven, The Netherlands.,Department of Nephrology, University Medical Centre, Utrecht, The Netherlands.,European Kidney Health Alliance, WG3 "Breakthrough Innovation", Brussels, Belgium
| | | | - Shuvo Roy
- University of California, California, San Francisco, USA
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16
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Caton E, Sharma S, Vilar E, Farrington K. Impact of incremental initiation of haemodialysis on mortality: a systematic review and meta-analysis. Nephrol Dial Transplant 2022; 38:435-446. [PMID: 36130107 PMCID: PMC9923704 DOI: 10.1093/ndt/gfac274] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Incremental haemodialysis initiation entails lower sessional duration and/or frequency than the standard 4 h thrice-weekly approach. Dialysis dose is increased as residual kidney function (RKF) declines. This systematic review evaluates its safety, efficacy and cost-effectiveness. METHODS We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases from inception to 27 February 2022. Eligible studies compared incremental haemodialysis (sessions either fewer than three times weekly or of duration <3.5 h) with standard treatment. The primary outcome was mortality. Secondary outcomes included treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness. The study protocol was prospectively registered. Risk of bias assessment used the Newcastle-Ottawa Scale and the revised Cochrane risk of bias tool, as appropriate. Meta-analyses were undertaken in Review Manager, Version 5.4. RESULTS A total of 644 records were identified. Twenty-six met the inclusion criteria, including 22 cohort studies and two randomized controlled trials (RCTs). Sample size ranged from 48 to 50 596 participants (total 101 476). We found no mortality differences (hazard ratio = 0.99; 95% CI 0.80-1.24). Cohort studies suggested similar hospitalization rates though the two small RCTs suggested less hospitalization after incremental initiation (relative risk = 0.31; 95% CI 0.18-0.54). Data on other treatment-emergent adverse events and quality of life was limited. Observational studies suggested reduced loss of RKF in incremental haemodialysis. This was not supported by RCT data. Four studies reported reduced costs of incremental treatments. CONCLUSIONS Incremental initiation of haemodialysis does not confer greater risk of mortality compared with standard treatment. Hospitalization may be reduced and costs are lower.
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Affiliation(s)
- Emma Caton
- Correspondence to: Emma Caton; E-mail: ; Twitter: @EmmaCaton459
| | - Shivani Sharma
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Enric Vilar
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK,Department of Renal Medicine, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Kenneth Farrington
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK,Department of Renal Medicine, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
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17
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Colbert G, Sannapaneni S, Lerma EV. Clinical Efficacy, Safety, Tolerability, and Real-World Data of Patiromer for the Treatment of Hyperkalemia. Drug Healthc Patient Saf 2022; 14:87-96. [PMID: 35860695 PMCID: PMC9292454 DOI: 10.2147/dhps.s338579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022] Open
Abstract
Hyperkalemia remains one of the most difficult consequences of disease state and treatment for patients with chronic kidney disease, heart failure, and diabetes. Controlling hyperkalemia can be difficult, but has become easier with the introduction of novel oral potassium binders. Patiromer was approved in 2015 for the treatment of hyperkalemia by the FDA in the United States. Several pivotal trials proved its efficacy, safety, and improved tolerability compared with previous hyperkalemia treatments. Additionally, many real-world publications and trials have given deeper insights into the capabilities of patiromer. We discuss improved disease state outcomes with combining patiromer with RAASi. This paper will also highlight new trials forthcoming that are highly anticipated to expand the possibilities in using patiromer to improve outcomes and populations.
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Affiliation(s)
- Gates Colbert
- Department of Internal Medicine, Division of Nephrology, Texas A&M College of Medicine, Dallas, TX, USA
- Correspondence: Gates Colbert, 3417 Gaston Ave, Suite 875, Dallas, TX, 75246, Tel +972-388-5970, Fax +972-388-5971, Email
| | - Shilpa Sannapaneni
- Department of Internal Medicine, Division of Nephrology, Texas A&M College of Medicine, Dallas, TX, USA
| | - Edgar V Lerma
- Department of Internal Medicine, Division of Nephrology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
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18
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Soi V, Faber MD, Paul R. Incremental Hemodialysis: What We Know so Far. Int J Nephrol Renovasc Dis 2022; 15:161-172. [PMID: 35520631 PMCID: PMC9065374 DOI: 10.2147/ijnrd.s286947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.
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Affiliation(s)
- Vivek Soi
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
- Wayne State University School of Medicine, Detroit, MI, USA
- Correspondence: Vivek Soi, Email
| | - Mark D Faber
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Ritika Paul
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
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