Global ESRD Costs Associated with a Short Daily Hemodialysis Program in the United States

Blood Access Outcomes Associated with Short Daily Hemodialysis

With the growing number of reports that daily hemodialysis (DHD) improves clinical outcomes and quality of life, there has been increased interest in the effects of more frequent venipunctures on blood accesses. Since 1996, we have converted 30 patients (27 in-center, 3 home) from conventional 3/week dialysis to short, daily, 6/week dialysis (sDHD). Twenty-five patients started for medical indications. End-stage renal disease (ESRD) causes were diabetes mellitus (in 7), hypertension (6), glomerulonephritis (8), hereditary nephritis (2), and other (7). Mean (±SD) age was 57 ± 16 years. Patients had an average of 3.8 major comorbidities in addition to ESRD. Thirty patients were followed on sDHD for 388 patient-months: 9 patients died after 4.2 ± 6.7 months, 3 were transplanted at 5.4 ± 2.2 months, and 3 were disenrolled at 9.3 ± 10.5 months. Fifteen patients remain on sDHD at 20.4 ± 14.1 months. Access problems for the 12 months prior to sDHD were compared to those that occurred while the patient was on sDHD. Problems were tracked by access type. There were 40 different accesses in 30 patients with a cumulative 28.07 access-years pre-DHD; 24 of these accesses were artificial bridge grafts (ABG) of either polytetrafluoroethylene or bovine material. There were 27 access problems pre-DHD, or 0.962 problems per access-year. On sDHD these same 30 patients had 41 accesses for 34.44 access-years; 23 of these were ABGs. There were 31 access problems or 0.900 problems per access-year. There were no significant differences in access problems comparing pre-DHD with on-sDHD, either in aggregate or when analyzed by access type. After 39 months of observation, there does not appear to be an increase in blood access problems when patients are converted from conventional dialysis to sDHD.

A crossover study of short daily haemodialysis

BACKGROUND

The benefits of daily haemodialysis (DHD) compared to conventional three times per week haemodialysis (CHD) have been described in a number of observational studies. Most of these previous studies however have not been performed with rigorous controls.

METHODS

We performed a crossover study following an A-B-A design: phase A was 4 weeks of thrice weekly dialysis, 3-4 h per treatment (CHD); phase B was 8 weeks of six times/week dialysis, each session being one-half of the usual time (DHD) and phase A with 4 weeks of thrice weekly dialysis (CHD) was repeated. Patients characteristics: n=12, six males; age 52+/-18 years, six diabetics.

RESULTS

Weekly single-pool Kt/V, equilibrated Kt/V and standard Kt/V of urea, and beta-2-microglobulin clearance values were greater during DHD. Eight of 12 patients who completed the study reported symptomatic benefits from DHD that partially or completely disappeared during the second period of CHD. Quality of life of patients improved during DHD. Three patients had problems with arteriovenous access during DHD. Average blood pressure was lower during DHD (systolic 139.5+/-22.7 mmHg) compared to the initial (147.7+/-21.4 mmHg, P<0.001) and last (146.4+/-20.0 mmHg, P<0.005) CHD periods. No significant changes in predialysis haemoglobin and the serum concentration of albumin, phosphate, beta-2-microglobulin or B-type natriuretic peptides (BNP) were observed, although BNP trended downward during DHD and returned to baseline level during the second period of CHD. The dose of erythropoietin did not change significantly. Patient compliance with the dialysis schedule was lower during DHD. Dialysis staff perceived an increased workload but felt that the patients benefited medically from DHD.

CONCLUSIONS

The results of this cross-over study suggest symptomatic benefits and decrease in blood pressure, but there are potential problems with compliance and vascular access during DHD.

Kinetics of urea and β2-microglobulin during and after short hemodialysis treatments

BACKGROUND

Daily short hemodialysis (HD) is often prescribed by simply doubling treatment frequency and halving treatment time; however, the effect of this prescription approach on the equilibrated HD dose (urea eKt/V) and whole body clearance for beta(2)-microglobulin has not been established.

METHODS

We compared urea and beta(2)-microglobulin kinetics during and 60 minutes after a short HD treatment and a conventional HD treatment in a crossover study on 22 maintenance HD patients: 16 male and 6 female, 61 +/- 18 (mean +/- standard deviation) years of age. One patient in each treatment modality was excluded from certain analyses because of missing data. Short and conventional HD treatments were essentially identical, except for treatment times, which were 116 +/- 14 and 241 +/- 27 minutes, respectively. Blood samples were collected at regular intervals during and after treatments, and additional blood and dialysate samples were collected at 60 minutes of treatment to evaluate dialyzer clearances.

RESULTS

Plasma water urea clearances measured directly across the dialyzer during short and conventional HD treatments were not different (255 +/- 23 mL/min and 255 +/- 28 mL/min, respectively). The 60-minute postdialysis blood urea nitrogen concentration rebounded more (P < 0.01) after short HD than conventional HD (5.9 +/- 3.1 vs. 4.0 +/- 1.5 mg/dL, respectively). Calculated urea eKt/V values using the Daugirdas-Schneditz rate equation were not different from those measured during conventional HD using the 60-minute postdialysis concentration but significantly overestimated measured urea eKt/V values during short HD. Postdialysis rebound of beta(2)-microglobulin concentrations was variable but similar after short and conventional HD treatments (0.1 +/- 3.4 vs. 0.7 +/- 1.8 mg/L, respectively). Whole body clearances of beta(2)-microglobulin calculated from predialysis and immediate (10-second) postdialysis serum concentrations during short and conventional HD treatments were not different from each other (42.9 +/- 24.1 vs. 41.9 +/- 22.4 mL/min, respectively).

CONCLUSION

These observations show that the Daugirdas-Schneditz rate equation is accurate in predicting urea eKt/V during conventional, but not during short, HD. In contrast, whole body clearances of beta(2)-microglobulin during short and conventional HD treatments were similar. We conclude that calculation of accurate estimates of urea eKt/V, but not clearances of beta(2)-microglobulin, differ during short and conventional HD treatments.

Computer simulation of small-solute and middle-molecule removal during short daily and long thrice-weekly hemodialysis

BACKGROUND

More intensive hemodialysis (HD) regimens (short daily and long thrice-weekly HD) provide potential opportunities for improved patient outcome. An adequate dialysis dose for these regimens cannot be established from the existing literature.

METHODS

Using computer simulation, we compared conventional HD with short daily HD and long thrice-weekly HD using two dose measures of solute clearance: equivalent renal clearance (EKR) and a generalized standard Kt/V (stdKt/V) for urea, creatinine, vitamin B12, inulin, and beta2-microglobulin. Solute kinetics were simulated using a variable-volume two-compartment mathematical model.

RESULTS

Calculated EKR values were greater during short daily HD compared with those during conventional HD by 16.9%, 15.5%, 16.1%, 5.2%, and 2.5% for urea, creatinine, vitamin B12, inulin, and beta(2)-microglobulin, respectively. Calculated stdKt/V values predicted more substantial increases in dose for all solutes. Increasing the time of dialysis from 4 to 8 hours three times weekly resulted in substantially greater stdKt/V and EKR values compared with both conventional and short daily HD. Solute clearances during short daily HD could be enhanced to approach those during long HD if treatment time was increased or very high surface area dialyzers were used with very high blood flow rates.

CONCLUSION

Dose measures for all molecules larger than urea increase with either increased frequency or, even more so, increased duration of dialysis. Prediction results of these models require confirmation in clinical studies. Furthermore, the relationship between increased dialysis dose and long-term clinical outcome during more intensive HD regimens requires examination in clinical trials.

Reduced requirement for erythropoietin with quotidian hemodialysis therapy

Quotidian (daily) hemodialysis has many potential advantages over conventional three times weekly hemodialysis, including improved control of anemia. However, previous reports do not consistently describe beneficial effects regarding anemia and erythropoietin requirements. We sought to determine whether erythropoietin dose is altered in this form of therapy, and elucidate the potential contributing factors. An analysis of an ongoing, nonrandomized, prospective trial of daily nocturnal, daily short, and their cohort of conventional hemodialysis controls was performed. Those patients who had completed 15 months of the trial were analyzed, which include nine patients in the quotidian dialysis group and nine cohort controls receiving conventional three times weekly dialysis. At 15 months, the weekly Kt/V in the quotidian group was 6.8 (+/-0.6) and 4.5 (+/-0.4) in the conventional group (p = 0.001). Mean erythropoietin dose fell in the quotidian group from 87 (+/-66) to 53 (+/-50) U/week per kg (p = 0.020). The mean hemoglobin rose from 115 (+/- 18) to 129 (+/- 14) g/L (p = 0.008). There was no significant change in erythropoietin dose or hemoglobin in the conventional hemodialysis group. Serum ferritin and the transferrin-saturation did not change significantly and remained above 100 microg/L and 20%, respectively, throughout. Serum albumin and C-reactive protein were similar between the quotidian and conventional dialysis groups and did not change over time. In patients who were receiving conventional thrice weekly hemodialysis, initiation of quotidian hemodialysis led to a 39% reduction in erythropoietin dose at 15 months, most likely due to the increased dose of delivered dialysis.

The economics of daily dialysis

Research suggests that daily hemodialysis improves clinical outcomes and patient quality of life when compared with conventional hemodialysis; however, little is known about its economic impact. In this article, we review the literature on the costs of daily hemodialysis (n = 170). We also present updated results from an economic model we constructed that compares 1-year treatment costs for short daily in-center, short daily at-home, nocturnal, and conventional hemodialysis. Clinical parameters for the model were drawn from our review of the clinical literature. Resource use during daily hemodialysis was modeled after the experience of 2 ongoing programs in the United States, a short daily program in California (n = 26) and a nocturnal program in Virginia (n = 13). Reports from the literature and our economic model suggest daily hemodialysis might provide better outcomes and savings when compared with conventional hemodialysis. However, larger, longer controlled studies are needed to see if daily dialysis fulfills these promises. We discuss several issues researchers should keep in mind in designing future studies about the economics of daily dialysis.

Hemeral (daily) hemodialysis

Hemodialysis is generally performed 3 times per week, a treatment prescription not based on optimizing the physiology of the normal kidney that maintains body homeostasis by removing water and waste products continuously and efficiently. Peritoneal dialysis might be continuous but it is not efficient. Daily hemodialysis is both frequent and efficient and theoretically should be superior to other forms of dialysis for renal replacement therapy. There is again a growing interest in daily hemodialysis (it was originally described in 1969), and a number of investigators in North America and Europe are using it. As yet, there have been no randomized prospective studies comparing hard outcomes in patients dialyzed by conventional 3-times-per-week hemodialysis with those treated with daily hemodialysis (either short high-efficiency or long, slow nocturnal). The London, Ontario, study is the first attempt to obtain comparative data. It is a 3-year study to compare daily dialysis patients with cohort controls. To date, the study shows that short daily dialysis does provide more dialysis based on Kt/V than standard therapy. However, predialysis blood urea values are not different because of improved nutrition (increased normalized protein from nitrogen appearance (nPNA) and serum albumin levels). Anemia is improved with less erythropoeitin usage in the study group. Phosphate control is good, but no better than by conventional dialysis and phosphate binders are still required unlike patients receiving nocturnal dialysis. Blood pressure and volume management is better with daily dialysis. So far, the study patients show a trend to less morbidity than their controls, but differences are not (as yet) statistically different. Blood access in daily dialysis dose not cause problems. Quality of life is significantly increased in a number of areas with daily dialysis. The economic impact of daily dialysis is not yet known; the general premise is that the higher dialysis costs attributable to an increment in treatments will be offset by increased wellness and less morbidity with the subsequent beneficial impact on drugs, hospitalizations, and so on. The provision of daily dialysis in the home has attractive economic implications. A considerable growth for this superior form of therapy is expected.