Vascular access survival and morbidity on daily dialysis: a comparative analysis of home and limited care haemodialysis

Home versus in-centre haemodialysis for people with kidney failure

BACKGROUND

Home haemodialysis (HHD) may be associated with important clinical, social or economic benefits. However, few randomised controlled trials (RCTs) have evaluated HHD versus in-centre HD (ICHD). The relative benefits and harms of these two HD modalities are uncertain. This is an update of a review first published in 2014. This update includes non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of HHD versus ICHD in adults with kidney failure.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2022 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. We searched MEDLINE (OVID) and EMBASE (OVID) for NRSIs.

SELECTION CRITERIA

RCTs and NRSIs evaluating HHD (including community houses and self-care) compared to ICHD in adults with kidney failure were eligible. The outcomes of interest were cardiovascular death, all-cause death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, vascular access interventions, central venous catheter insertion/exchange, vascular access infection, parathyroidectomy, wait-listing for a kidney transplant, receipt of a kidney transplant, quality of life (QoL), symptoms related to dialysis therapy, fatigue, recovery time, cost-effectiveness, blood pressure, and left ventricular mass.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed if the studies were eligible and then extracted data. The risk of bias was assessed, and relevant outcomes were extracted. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was performed on outcomes where there was sufficient data.

MAIN RESULTS

From the 1305 records identified, a single cross-over RCT and 39 NRSIs proved eligible for inclusion. These studies were of varying design (prospective cohort, retrospective cohort, cross-sectional) and involved a widely variable number of participants (small single-centre studies to international registry analyses). Studies also varied in the treatment prescription and delivery (e.g. treatment duration, frequency, dialysis machine parameters) and participant characteristics (e.g. time on dialysis). Studies often did not describe these parameters in detail. Although the risk of bias, as assessed by the Newcastle-Ottawa Scale, was generally low for most studies, within the constraints of observational study design, studies were at risk of selection bias and residual confounding. Many study outcomes were reported in ways that did not allow direct comparison or meta-analysis. It is uncertain whether HHD, compared to ICHD, may be associated with a decrease in cardiovascular death (RR 0.92, 95% CI 0.80 to 1.07; 2 NRSIs, 30,900 participants; very low certainty evidence) or all-cause death (RR 0.80, 95% CI 0.67 to 0.95; 9 NRSIs, 58,984 patients; very low certainty evidence). It is also uncertain whether HHD may be associated with a decrease in hospitalisation rate (MD -0.50 admissions per patient-year, 95% CI -0.98 to -0.02; 2 NRSIs, 834 participants; very low certainty evidence), compared with ICHD. Compared with ICHD, it is uncertain whether HHD may be associated with receipt of kidney transplantation (RR 1.28, 95% CI 1.01 to 1.63; 6 NRSIs, 10,910 participants; very low certainty evidence) and a shorter recovery time post-dialysis (MD -2.0 hours, 95% CI -2.73 to -1.28; 2 NRSIs, 348 participants; very low certainty evidence). It remains uncertain if HHD may be associated with decreased systolic blood pressure (SBP) (MD -11.71 mm Hg, 95% CI -21.11 to -2.46; 4 NRSIs, 491 participants; very low certainty evidence) and decreased left ventricular mass index (LVMI) (MD -17.74 g/m2, 95% CI -29.60 to -5.89; 2 NRSIs, 130 participants; low certainty evidence). There was insufficient data to evaluate the relative association of HHD and ICHD with fatigue or vascular access outcomes. Patient-reported outcome measures were reported using 18 different measures across 11 studies (QoL: 6 measures; mental health: 3 measures; symptoms: 1 measure; impact and view of health: 6 measures; functional ability: 2 measures). Few studies reported the same measures, which limited the ability to perform meta-analysis or compare outcomes. It is uncertain whether HHD is more cost-effective than ICHD, both in the first (SMD -1.25, 95% CI -2.13 to -0.37; 4 NRSIs, 13,809 participants; very low certainty evidence) and second year of dialysis (SMD -1.47, 95% CI -2.72 to -0.21; 4 NRSIs, 13,809 participants; very low certainty evidence).

AUTHORS' CONCLUSIONS

Based on low to very low certainty evidence, HHD, compared with ICHD, has uncertain associations or may be associated with decreased cardiovascular and all-cause death, hospitalisation rate, slower post-dialysis recovery time, and decreased SBP and LVMI. HHD has uncertain cost-effectiveness compared with ICHD in the first and second years of treatment. The majority of studies included in this review were observational and subject to potential selection bias and confounding, especially as patients treated with HHD tended to be younger with fewer comorbidities. Variation from study to study in the choice of outcomes and the way in which they were reported limited the ability to perform meta-analyses. Future research should align outcome measures and metrics with other research in the field in order to allow comparison between studies, establish outcome effects with greater certainty, and avoid research waste.

[Low flux dialysate daily home hemodialysis: A result for the 62 first French and Belgian patients]

Since 2011, a new device is available for low flux dialysate quotidian home hemodialysis in France and Belgium. This study aims to evaluate the characteristics and dialysis prescriptions for Nx Stage System One™ users. We retrospectively included patients trained between 2011 and 2013 in France and Belgium. We collected data concerning their clinical features, their dialysis prescriptions, their laboratory parameters until 6 months of dialysis and, reason for dropping in case of cessation. Sixty-two patients from 31 centers, aged 48±18 years old, with a sex ratio 46/16 (M/F) are included with a median Charlson comorbidity index of 1 [0-3]. Of these patients, 71% are anuric and have been on dialysis for a mean time of 136.6±125 months. Previously, most of them had been taken care of in satellite units of dialysis (45%) and 14% are incident patients. In total, A total of 60% have an arterio-veinous fistula (AVF), with 18 patients using the Buttonhole system and 2 patients have a tunneled catheter. Median time for training was 26.5 days (17-45). Among the patients, 69% are dialyzed 6 days a week, during a mean time of 142.5±20 minutes with a volume of 20.9±3 liters of dialysate and without anticoagulant (63%). Predialytic levels of hemoglobin, creatinin, urea, phosphorus and β2microglobulin remain stable. On the contrary, there is a significant improvement of albumin and bicarbonate levels. Technique survival was 75% at 1 year, and major reason for cessation was kidney transplant. It seems that this device fits for young patients, with few comorbidities and a long past in renal chronic failure. These results suggest that dialysis adequacy is acceptable despite low dialysate volumes but need confirmation with a longer follow up and a larger cohort.

French patients on daily hemodialysis: clinical characteristics and treatment trajectories

BACKGROUND

Increasing the weekly frequency of hemodialysis sessions has positive effects, on the control of several biological data of patients. However, knowledge about Daily HemoDialysis (DHD) practices is limited in France. The aim of the present study was to describe the characteristics and treatment trajectories of all French patients undergoing DHD.

METHODS

All patients older than 18 years who started DHD between 2003 and 2012 in France were included and followed until December 31, 2013. The patients' demographic and clinical characteristics and treatment modalities were extracted from the French Renal Epidemiological and Information Network (REIN) registry.

RESULTS

During the inclusion period, 753 patients started DHD in France. Based on their median age (64 years), patients were classified in two groups: "old" group (≥64 years) and "young" group (<64 years). Patients in the old group had more comorbidities than in the young group: 48 % had diabetes (vs 29 % in the young group), 17 % an active malignancy (vs 10 %) and 80 % ≥1 cardiovascular disease (vs 41 %). Concerning patients' treatment trajectories, 496 (66 %) patients started with another dialysis before switching to DHD and 257 (34 %) directly with DHD. At the end of the follow-up, 69 % of patients in the old group were dead (27.4 % in the young group) and kidney transplantation was more frequent in the young group (30.4 % vs 0.5 %).

CONCLUSION

In France, DHD is proposed not only to young in rather good clinical conditions and waiting for kidney transplantation, but also to old and frail patients with higher mortality.

Long-term effects of daily hemodialysis on vascular access outcomes: a prospective controlled study

Daily hemodialysis has been associated with surrogate markers of improved survival among hemodialysis patients. A potential disadvantage of daily hemodialysis is that frequent vascular access cannulations may affect long-term vascular access patency. The study design was a 4-year, nonrandomized, contemporary control, prospective study of 77 subjects in either 3-h daily hemodialysis (six 3-h dialysis treatments weekly; n = 26) or conventional dialysis (three 4-h dialysis treatments weekly; n = 51). Outcomes of interest were vascular access procedures (fistulagram, thrombectomy and access revision). Total access procedures (fistulagram, thrombectomy and access revision) were 543.2 (95% confidence interval [CI]: 432.9, 673.0) per 1000 person-years in the conventional dialysis group vs. 400.8 (95% CI: 270.2, 572.4) per 1000 person-years in the daily hemodialysis dialysis group (incidence rate ratio = 0.74 with 95% CI: from 0.40 to 1.36, P = 0.33), after adjusting for age, gender, diabetes status, serum phosphorus, hemoglobin level and erythropoietin dose, there was no significant differences in incidence rate of total access procedures (P-value > 0.05). There was no difference in time to first access revision between the daily dialysis and the conventional dialysis groups after adjustment for covariates (hazard ratio = 0.99 95% CI: 0.42, 2.36, P = 0.96). Daily hemodialysis is not associated with increased vascular access complications, or increased vascular access failure rates.

Clinical effects of buttonhole cannulation method on hemodialysis patients

Although the buttonhole cannulation method is now widely used as an alternative to the rope-ladder method in most countries, only the latter method is used in Korea. This study was performed to investigate clinical benefit of the buttonhole technique for arteriovenous fistula (AVF) cannulation in maintenance hemodialysis (HD) patients. Thirty-two patients receiving HD via mature AVF were included and AVF cannulation was performed by 20 experienced nurses. During the 8 weeks, AVFs were cannulated by the rope-ladder method with 15-gauge sharp needles. After creating of 2 pairs of tunnel tracks by sharp needles for 7 weeks, AVFs were cannulated by the buttonhole method using 15-gauge blunt needles during the 16 weeks. Vascular access blood flow rate (BFR), dialysis venous pressure (DVP), and dialysis adequacy (Kt/V) were measured within the first week of the two cannulation methods. Cannulation pain, hemostasis time, and nurse's stress were evaluated at the end of the two methods. There were no statistical differences in vascular access BFR (P = 0.139), DVP (P = 0.152), and dialysis adequacy (P = 0.343) between the two methods. However, the buttonhole method shortened hemostasis time (P = 0.001) and decreased cannulation pain (P = 0.001) as well as nurse's stress (P = 0.001) compared with the rope-ladder method. In conclusion, the buttonhole cannulation method improves hemostasis time, cannulation pain, and nurse's stress without a change in vascular access BFR and dialysis adequacy in HD patients.

Intensified hemodialysis regimens: neglected treatment options for children and adolescents

During recent years, the importance of intensified dialysis regimens has gathered increasing interest, especially after the Hemodialysis (HEMO) Study Group reported that a higher dose of thrice-weekly hemodialysis failed to improve clinical outcomes. Long nocturnal hemodialysis (three to six times per week) or short daily hemodialysis are the currently used forms of intensified dialysis. There is substantial evidence for cardiovascular and quality-of-life improvements as well as financial benefits with intensified hemodialysis. Preliminary experience with daily hemodialysis and hemodiafiltration in children has been reported. Given the continuing shortage of donor organs for kidney transplantation, the increasing incidence of end-stage renal disease (ESRD) and recognition of the deleterious effects of long-lasting ESRD, growth retardation, and poor social rehabilitation, more intensified dialysis regimens are a much-needed therapeutical option in both adults and children.

Hospitalization rates in daily home hemodialysis versus peritoneal dialysis patients in the United States

BACKGROUND

Daily hemodialysis (DHD) is associated with improvements in hypertension, left ventricular hypertrophy, mineral metabolism, nutrition, and quality of life, but efficacy is uncertain because of potential selection bias. To reduce the influence of selection bias, we sought to compare hospital admissions for our population of DHD patients with peritoneal dialysis (PD) patients who initiated training during the same period. We also compared our hospital data with the US Renal Data Service database.

STUDY DESIGN

Prospective nonrandomized cohort study.

SETTING & PARTICIPANTS

22 (16 male) DHD and 64 (33 male) PD patients who initiated training between March 2003 and September 2007 at our center and remained in our program for at least 6 months.

PREDICTORS

Dialysis modality (DHD or PD).

OUTCOMES

Number of hospital admissions and length of stay.

RESULTS

Median age at initiation of training was 52 years (range, 33 to 76 years) for DHD patients versus 54 years (range, 21 to 82 years) for PD patients (P = 0.5), and median vintage was 23 months (range, 0 to 145 months) for DHD patients versus 0 month (range, 0 to 244 months) for PD patients (P < 0.001). Fifty percent of DHD and 56% of PD patients had a diagnosis of diabetes mellitus (P = 0.8). We observed 27 DHD and 82 PD admissions (0.68 and 0.76 admissions/patient-year, respectively) during the study period (P = 0.5). We also observed 130 DHD and 605 PD hospital days (3.3 and 5.6 days/patient-year, respectively; P < 0.001).

LIMITATIONS

Patients were not randomly assigned between the study group and control group; study group was small.

CONCLUSIONS

Our study suggests that despite similar patient demographics, patients treated with DHD spend fewer days in the hospital than PD patients in the United States. Although selection bias could partially explain our lower hospitalization rate, other factors, including improvements in blood pressure control, nutrition, and fewer fluctuations in dry weight, probably contributed to the stability of our patients.

Quotidian hemodialysis and inflammation associated with chronic kidney disease

The mortality rate of chronic dialysis patients in the United States is 24% per year per the 2006 United States Renal Data System. Although there have been marked improvements in dialysis technology, cardiovascular disease is the principal cause of mortality in end-stage renal disease patients. Inflammation and left ventricular hypertrophy both contribute to atherosclerosis. Hemodialysis 3 times a week is the most commonly used form of dialysis in the United States. The multicenter hemodialysis (HEMO) study hypothesized that an increase in dialysis dose and use of high-flux membranes would improve mortality and decrease morbidity. This study failed to show decreases in mortality. In other studies, however, there appears to be improved morbidity with more frequent dialysis including daily nocturnal hemodialysis and short-daily hemodialysis. The more frequent dialysis may have some beneficial effect on the inflammatory process that occurs in end-stage renal disease.

Daily home hemodialysis at a health maintenance organization: three-year experience

Daily home hemodialysis (DHD), 5 to 7 short-duration hemodialysis treatments per week, promotes self-care and has beneficial effects on a number of clinical outcomes including blood pressure and volume control, electrolyte balance, uremic symptoms and sequelae, and quality of life. We sought to demonstrate that DHD is feasible and confers clinical benefits that permit savings in overall healthcare costs despite expenditures on program infrastructure and supplies. We examined the following outcomes monthly for all patients: laboratory values, dialysis adequacy, hospital admission records, surgical and interventional radiology records, and prescription medication usage. Twelve patients completed training in our home hemodialysis unit between April 2003 and April 2006. The mean age at the time of training was 58 years and mean vintage was 62 months. The mean treatment time was 147 min, and the mean number of treatments performed was 5.3 per week. When 1 patient with morbid obesity was excluded due to intentional weight loss, the mean dry weight at initiation of training was 71.9+/-12.4 kg and increased to 74.3+/-12.4 kg by the end of the study (p=0.66). The mean albumin increased from a baseline of 3.9+/-0.3 to 4.3+/-1.1 gm/dL during DHD (p=0.0015). The mean serum phosphorus levels were 5.4+/-1.4 mg/dL. Phosphate binder usage increased from a mean baseline of 2.6+/-1.4 to 4.2+/-2.6 tablets per meal during DHD (p=0.08). The mean delivered single pool Kt/V was 0.87 per treatment. During the 234 months studied, there were 11 hospital admissions (0.56 admissions per patient per year), with a mean length of stay of 3.7 days. Our results demonstrate that DHD improves nutritional status and decreases hospital admissions for dialysis-dependent patients.

High-efficiency short daily haemodialysis—morbidity and mortality rate in a long-term study

BACKGROUND

In conventional haemodialysis (CHD), the morbidity and mortality rate is unacceptably high; consequently, variations in the length and frequency of the haemodialysis sessions have been studied to reduce the complications of dialysis treatment. In this sense, high-efficiency short daily haemodialysis (SDHD) has been proposed as an alternative for patients on renal replacement therapy. In this study, we have related our experience with this dialysis modality.

METHODS

Twenty-six patients (16 males, mean age 35.6 +/- 14.7 years) were treated by SDHD for 33.6 +/- 18.5 months (range 6-57 months). The mean time on CHD before the switch to SDHD was 25.5 +/- 31.9 months (range 1-159 months). In 23 (88.5%) patients, native arteriovenous fistulae were used for vascular access. SDHD was performed six times a week, 1.5-2 h per session, and high flux polysulfone dialysers (surface area: 1.8 m(2)) were employed. The blood flow and dialysate flow rate were 350 and 800 ml/min, respectively.

RESULTS

In this trial, the patient survival was 100%. The vascular access survival after 12, 24, 36 and 48 months on SDHD was 100, 89, 89 and 80%, respectively. There were three failures of vascular access in 72.7 patient-years (0.04 failures/patient-year). In 15 patients on SDHD during 36 consecutive months, the vascular access survival after 12, 24, 36 and 48 months was 100, 93, 93 and 84%, respectively. Also, in this group of patients, there were 0.27 hospitalizations/patient-year and 1.24 days of hospitalizations/patient-year.

CONCLUSIONS

We concluded that in a long-time study of patients on SDHD the morbidity and mortality rate is very low. Furthermore, we observed that failures of vascular access are not a significant problem. Consequently, we believe that SDHD is a powerful renal replacement therapy for treatment of patients on maintenance haemodialysis.

Daily Hemodialysis: A Systematic Review

Several studies have reported improved outcomes with daily hemodialysis (DHD), but the strength of this evidence has not been evaluated. The published evidence on DHD was synthesized and its quality rated to inform need and sample size calculations for a randomized trial. Citations were identified in MEDLINE and EMBASE using validated search strategies. Dialysis journals that were not indexed and bibliographies of relevant articles were hand-searched. Two authors reviewed all citations. Articles that reported original data on five or more adults who were receiving DHD (1.5 to 3 h, 5 to 7 d/wk) for > or = 3 mo were included. Twenty-five articles reporting 14 unique populations with 268 patients (five to 72 per study) met inclusion criteria. Of the 14 cohorts, 13 were studied with an observational design, 10 were studied prospectively, and four had parallel control groups. Mean age ranged form 41 to 64 yr, mean time on dialysis was 2 to 11 yr, 0 to 28% of patients had diabetes, > 90% had arteriovenous fistulae, and > 50% were dialyzed at home. Most data were described at < or = 12 mo of follow-up. Outcomes included quality of life, cardiovascular disease, erythropoiesis, nutritional status, hospitalizations, and vascular access failures. Reporting was too heterogeneous to allow pooling of data. Ten of 11 studies suggested improvements in blood pressure; findings for other outcomes varied. Discontinuation of DHD occurred in 0 to 57% in-center and 0 to 15% home patients. Studies of DHD are limited by small sample size, nonideal control groups, selection and dropout biases, and paucity of data on potential risks. Randomized trials with adequate statistical power are required to establish the efficacy and the safety of DHD.

Quotidian dialysis – update 2005

PURPOSE OF REVIEW

The interest in quotidian hemodialysis has increased further after the HEMO study reported that high-dose thrice-weekly hemodialysis failed to improve clinical outcomes. This, in combination with a significant volume of newly published data, made a review of the topic of quotidian hemodialysis timely.

RECENT FINDINGS

The published research has revealed further evidence of cardiovascular and quality-of-life improvements as well as financial benefits with quotidian hemodialysis. Accrued worldwide experience has confirmed the previously published benefits of quotidian hemodialysis. There has been a significant effort by industry to produce patient-friendly machines for home hemodialysis. Reports on the use of daily hemodialysis and hemodiafiltration in children have appeared. An international registry of patients on quotidian hemodialysis has been created. The need for modification of the funding mechanisms and the lack of prospective randomized controlled studies on quotidian hemodialysis led to the funding of such studies by the National Institutes of Health in collaboration with Centers for Medicare and Medicaid services to be completed by 2008. The proper funding for daily home hemodialysis was secured in the province of British Columbia, Canada, and is under consideration elsewhere.

SUMMARY

There is increasing evidence confirming that quotidian hemodialysis improves clinical outcomes in a cost-efficient manner. Provided that the reimbursement issues are resolved these modalities may be utilized extensively at home as well as in the in-center facilities. The revitalization of home hemodialysis will compensate for the decline in utilization of continuous ambulatory peritoneal dialysis and the nursing shortage encountered in most countries.