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Cheetham MS, Ethier I, Krishnasamy R, Cho Y, Palmer SC, Johnson DW, Craig JC, Stroumza P, Frantzen L, Hegbrant J, Strippoli GF. Home versus in-centre haemodialysis for people with kidney failure. Cochrane Database Syst Rev 2024; 4:CD009535. [PMID: 38588450 PMCID: PMC11001293 DOI: 10.1002/14651858.cd009535.pub3] [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] [Indexed: 04/10/2024]
Abstract
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.
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Affiliation(s)
- Melissa S Cheetham
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Isabelle Ethier
- Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Health Innovation and Evaluation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Rathika Krishnasamy
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Australasian Kidney Trials Network, Translational Research Institute, Woolloongabba, Australia
| | - Yeoungjee Cho
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Paul Stroumza
- Medical Office, Diaverum Marseille, Marseille, France
| | - Luc Frantzen
- Medical Office, Diaverum Marseille, Marseille, France
| | - Jorgen Hegbrant
- Division of Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Zhu Y. Usage and Health Outcomes of Home Hemodialysis vs Center Hemodialysis in Racial/Ethnic Minority Groups in the United States a Quantitative Research in 2016-2019 USRDS Using Aday-Anderson Framework and Multiple Regression Models. Patient Relat Outcome Meas 2024; 15:1-16. [PMID: 38222923 PMCID: PMC10787550 DOI: 10.2147/prom.s416279] [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: 04/28/2023] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Home hemodialysis (HHD) offers patients with end-stage kidney disease (ESKD) greater flexibility and advantages of health outcomes over center hemodialysis (CHD). This study aims to investigate the differences between home and center hemodialysis with a focus on racial/ethnic minorities. Methods The US Renal Disease System (USRDS) 2019 patient core data containing mortality and hospitalization which are cumulative since 2010 were merged with 2016-2019 Medicare clinical claims. To assess demographic and medical factors adjusted utilization and mortality of HHD vs CHD within every racial/ethnic cohort, logistic regression was used, and negative binomial regression was conducted to analyze the number of hospitalizations. Results Evaluating 548,453 (97.48%) CHD patients and 14,202 (2.52%) HHD patients with Whites 47%, Blacks 32%, Hispanics 15%, Asians 4%, and other minorities 2%, the outcomes from adjusted regressions showed that: 1) minorities were significantly less likely to use HHD than Whites (Blacks: OR, 0.568, 95% CI, 0.546-0.592; Hispanics: OR, 0.510, 95% CI, 0.477-0.544; Asians: OR, 0.689, 95% CI, 0.619-0.766; Others: OR, 0.453, 95% CI, 0.390-0.525; p < 0.001); 2) most minority patients were younger and had fewer comorbidities than Whites, and all minority groups displayed significantly lower mortality and hospitalization incidences than the White group with adjustment on multiple covariates; 3) in the overall and main racial/ethnic cohorts, HHD showed a significantly lower risk of death than CHD after confounding for major risk factors (overall cohort: OR, 0.686, 95% CI, 0.641-0.734; White: OR, 0.670, 95% CI, 0.612-0.734; Blacks: OR, 0.717, 95% CI, 0.644-0.799; Hispanics: OR, 0.715, 95% CI, 0.575-0.889; Others: OR, 0.473, 95% CI, 0.265-0.844). Conclusion There are substantial racial/ethnic variations in home hemodialysis use and health outcomes in the United States.
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Affiliation(s)
- Ying Zhu
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, USA
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Platnich JM, Pauly RP. Patient Training and Patient Safety in Home Hemodialysis. Clin J Am Soc Nephrol 2024:01277230-990000000-00327. [PMID: 38190130 DOI: 10.2215/cjn.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.
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Affiliation(s)
- Jaye M Platnich
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Wilson L, Gress AF, Frassetto L, Sarathy H, Gress EA, Fissell WH, Roy S. Patient Preference Trade-offs for Next-Generation Kidney Replacement Therapies. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00257. [PMID: 37874941 PMCID: PMC10843336 DOI: 10.2215/cjn.0000000000000313] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Next-generation implantable and wearable KRTs may revolutionize the lives of patients undergoing dialysis by providing more frequent and/or prolonged therapy along with greater mobility compared with in-center hemodialysis. Medical device innovators would benefit from patient input to inform product design and development. Our objective was to determine key risk/benefit considerations for patients with kidney failure and test how these trade-offs could drive patient treatment choices. METHODS We developed a choice-based conjoint discrete choice instrument and surveyed 498 patients with kidney failure. The choice-based conjoint instrument consisted of nine attributes of risk and benefit pertinent across KRT modalities. Attributes were derived from literature reviews, patient/clinician interviews, and pilot testing. The risk attributes were serious infection, death within 5 years, permanent device failure, surgical requirements, and follow-up requirements. The benefit attributes were fewer diet restrictions, improved mobility, pill burden, and fatigue. We created a random, full-profile, balanced overlap design with 14 choice pairs plus five fixed tasks to test validity. We used a mixed-effects regression model with attribute levels as independent predictor variables and choice decisions as dependent variables. RESULTS All variables were significantly important to patient choice preferences, except follow-up requirements. For each 1% higher risk of death within 5 years, preference utility was lower by 2.22 ( β =-2.22; 95% confidence interval [CI], -2.52 to -1.91), while for each 1% higher risk of serious infection, utility was lower by 1.38 ( β =-1.46; 95% CI, -1.77 to -1.00) according to comparisons of the β coefficients. Patients were willing to trade a 1% infection risk and 0.5% risk of death to gain complete mobility and freedom from in-center hemodialysis ( β =1.46; 95% CI, 1.27 to 1.64). CONCLUSIONS Despite an aversion to even a 1% higher risk of death within 5 years, serious infection, and permanent device rejection, patients with kidney failure suggested that they would trade these risks for the benefit of complete mobility.
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Affiliation(s)
- Leslie Wilson
- Department of Pharmacy, University of California, San Francisco, San Francisco, California
| | - Anne F. Gress
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
| | - Lynda Frassetto
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Harini Sarathy
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Elizabeth A. Gress
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
| | | | - Shuvo Roy
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
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Jena R, Aggarwal A, Choudhary GR, Bajpai NK. Current Status and Future of Artificial Kidney in Humans. Indian J Nephrol 2022; 32:531-538. [PMID: 36704585 PMCID: PMC9872927 DOI: 10.4103/ijn.ijn_240_21] [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: 06/07/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022] Open
Abstract
The number of patients needing renal replacement therapy (RRT) is increasing rapidly with an increase in lifestyle diseases such as diabetes, hypertension, and metabolic syndrome. Kidney transplantation, whenever feasible, is the most preferred mode of RRT. However, there is a growing shortage of donor kidneys for transplantation. While dialysis is partially able to perform the filtration and excretion function of the kidneys, it is still not able to perform the other renal tubular and endocrine functions of a normal kidney and has quality-of-life issues with significant long-term morbidity. The need of the hour is to develop an ideal artificial kidney that would be wearable or implantable and would be able to perform the complete excretory, filtration, tubular, endocrine, and metabolic functions of the kidney while preserving the quality of life and minimizing complications. In this review, we discuss the characteristics of an ideal artificial kidney, the challenges of developing such a device, a brief description of the past and current work on this topic, and what the artificial kidney of the future should look like.
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Affiliation(s)
- Rahul Jena
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Amit Aggarwal
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Gautam R Choudhary
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nitin K Bajpai
- Department of Nephrology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Rabbani R, Noel E, Boyle S, Balina H, Ali S, Fayoda B, Khan WA. Role of Antihypertensives in End-Stage Renal Disease: A Systematic Review. Cureus 2022; 14:e27058. [PMID: 36000139 PMCID: PMC9389027 DOI: 10.7759/cureus.27058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/05/2022] Open
Abstract
The primary goal of this research is to identify the factors of intradialytic hypertension in hemodialysis patients and stabilize blood pressure (BP) even without antihypertensive medicines. There are various treatment alternatives for lowering BP in these patients, many of which do not require extra pharmacological therapy (e.g. long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in addition to the reduction of dialysate sodium concentration). These parameters provide good monitoring of BP, even with previously diagnosed hypertension. The adjustment of the extracellular volume with a low incidence of intradialytic hypotensive episodes is the most plausible explanation for this outcome. We did a systematic evaluation of all published articles since 1994 to evaluate antihypertensive drug outcomes in hemodialysis patients. All articles were searched in the English language using PubMed and Google Scholar databases. The screening techniques, study selection, data extraction procedures, and risk evaluation of bias were done using specified criteria and overseen by one of the senior writers with the application of quality assessment tools to the final articles. Data were searched using regular and MeSH (Medical Subject Headings) keywords. Although substantial developments have emerged in the medical field, there is still a significant knowledge gap in the sector, particularly when it comes to BP guidelines and therapy choices for hypertensive hemodialysis patients. Until additional data are available, we should treat hypertension in hemodialysis with the use of active pursuit of euvolemia using dry weight probing and reduction of salt excess.
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Roumeliotis A, Roumeliotis S, Chan C, Pierratos A. Cardiovascular Benefits of Extended-Time Nocturnal Hemodialysis. Curr Vasc Pharmacol 2021; 19:21-33. [PMID: 32234001 DOI: 10.2174/1570161118666200401112106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/09/2023]
Abstract
Hemodialysis (HD) remains the most utilized treatment for End-Stage Kidney Disease (ESKD) globally, mainly as conventional HD administered in 4 h sessions thrice weekly. Despite advances in HD delivery, patients with ESKD carry a heavy cardiovascular morbidity and mortality burden. This is associated with cardiac remodeling, left ventricular hypertrophy (LVH), myocardial stunning, hypertension, decreased heart rate variability, sleep apnea, coronary calcification and endothelial dysfunction. Therefore, intensive HD regimens closer to renal physiology were developed. They include longer, more frequent dialysis or both. Among them, Nocturnal Hemodialysis (NHD), carried out at night while asleep, provides efficient dialysis without excessive interference with daily activities. This regimen is closer to the physiology of the native kidneys. By providing increased clearance of small and middle molecular weight molecules, NHD can ameliorate uremic symptoms, control hyperphosphatemia and improve quality of life by allowing a liberal diet and free time during the day. Lastly, it improves reproductive biology leading to successful pregnancies. Conversion from conventional to NHD is followed by improved blood pressure control with fewer medications, regression of LVH, improved LV function, improved sleep apnea, and stabilization of coronary calcifications. These beneficial effects have been associated, among others, with better extracellular fluid volume control, improved endothelial- dependent vasodilation, decreased total peripheral resistance, decreased plasma norepinephrine levels and restoration of heart rate variability. Some of these effects represent improvements in outcomes used as surrogates of hard outcomes related to cardiovascular morbidity and mortality. In this review, we consider the cardiovascular effects of NHD.
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Affiliation(s)
- Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christopher Chan
- University Health Network, Toronto General Hospital, Toronto, Canada
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8
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Rastogi A, Lerma EV. Anemia management for home dialysis including the new US public policy initiative. Kidney Int Suppl (2011) 2021; 11:59-69. [PMID: 33777496 PMCID: PMC7983021 DOI: 10.1016/j.kisu.2020.12.005] [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: 10/02/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/28/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.
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Affiliation(s)
- Anjay Rastogi
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Edgar V. Lerma
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Section of Nephrology, Oak Lawn, Illinois, USA
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Jansz TT, Özyilmaz A, van Reekum FE, Boereboom FTJ, de Jong PA, Verhaar MC, van Jaarsveld BC. Progression of coronary artery calcification in conventional hemodialysis, nocturnal hemodialysis, and kidney transplantation. PLoS One 2020; 15:e0244639. [PMID: 33378347 PMCID: PMC7773242 DOI: 10.1371/journal.pone.0244639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/10/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Cardiovascular disease is the leading cause of death in end-stage renal disease (ESRD) and is strongly associated with vascular calcification. An important driver of vascular calcification is high phosphate levels, but these become lower when patients initiate nocturnal hemodialysis or receive a kidney transplant. However, it is unknown whether nocturnal hemodialysis or kidney transplantation mitigate vascular calcification. Therefore, we compared progression of coronary artery calcification (CAC) between patients treated with conventional hemodialysis, nocturnal hemodialysis, and kidney transplant recipients. Methods We measured CAC annually up to 3 years in 114 patients with ESRD that were transplantation candidates: 32 that continued conventional hemodialysis, 34 that initiated nocturnal hemodialysis (≥4x 8 hours/week), and 48 that received a kidney transplant. We compared CAC progression between groups as the difference in square root transformed volume scores per year (ΔCAC SQRV) using linear mixed models. Reference category was conventional hemodialysis. Results The mean age of the study population was 53 ±13 years, 75 (66%) were male, and median dialysis duration was 28 (IQR 12–56) months. Median CAC score at enrollment was 171 (IQR 10–647), which did not differ significantly between treatment groups (P = 0.83). Compared to conventional hemodialysis, CAC progression was non-significantly different in nocturnal hemodialysis -0.10 (95% CI -0.77 to 0.57) and kidney transplantation -0.33 (95% CI -0.96 to 0.29) in adjusted models. Conclusions Nocturnal hemodialysis and kidney transplantation are not associated with significantly less CAC progression compared to conventional hemodialysis during up to 3 years follow-up. Further studies are needed to confirm these findings, to determine which type of calcification is measured with CAC in end-stage renal disease, and whether that reflects cardiovascular risk.
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Affiliation(s)
- Thijs T. Jansz
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Dianet Dialysis Centers, Utrecht, The Netherlands
| | - Akin Özyilmaz
- Dialysis Center Groningen, Groningen, The Netherlands
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Franka E. van Reekum
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Pim A. de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Brigit C. van Jaarsveld
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- * E-mail:
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10
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Fotheringham J, Sajjad A, Stel VS, McCullough K, Karaboyas A, Wilkie M, Bieber B, Robinson BM, Massy ZA, Jager KJ. The association between longer haemodialysis treatment times and hospitalization and mortality after the two-day break in individuals receiving three times a week haemodialysis. Nephrol Dial Transplant 2020; 34:1577-1584. [PMID: 30820580 PMCID: PMC6735689 DOI: 10.1093/ndt/gfz007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND On the first haemodialysis (HD) day after the 2-day break in three times a week (3×W) in-centre HD, mortality and hospitalization are higher. If longer HD sessions prescribed 3×W is associated with a reduction in these events is unknown. METHODS HD session length in 19 557 prevalent European in-centre 3×W HD patients participating in the Dialysis Outcomes and Practice Patterns Study (1998-2011) were categorized into <200, 200-225, 226-250 or >250 min. Standardized event rates on the first (HD1) versus the second (HD2) HD day after the 2-day break, with supporting Cox proportional hazards models adjusted for patient and dialysis characteristics, were generated for all-cause mortality, all-cause hospitalization, out-of-hospital death and fluid overload hospitalization. RESULTS By comparing HD1 with HD2, increased rates of all endpoints were observed (all P < 0.002). As HD session lengthened across the four groups, all-cause mortality per 100 patient-years on the HD1 (23.0, 20.4, 16.4 and 14.6) and HD2 (26.1, 13.3, 13.4 and 12.1) reduced. Similar improvements were observed for out-of-hospital death but were less marked for hospitalization endpoints. However, even patients dialysing >250 min were at significantly greater risk on HD1 when compared with their HD2 for out-of-hospital death [hazard ratio (HR) = 2.1, 95% CI 1.0-4.3], all-cause hospitalization (HR = 1.3, 95% CI 1.2-1.4) and fluid overload hospitalization (HR = 3.2, 95% CI 1.8-6.0). CONCLUSIONS Despite the association between reduced mortality across all dialysis days in patients performing longer sessions, elevated risk on the first dialysis day relative to the second persists even in patients dialysing 4.5 h 3×W.
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Affiliation(s)
- James Fotheringham
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK.,School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ayesha Sajjad
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Vianda S Stel
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | | | - Martin Wilkie
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, University of Versailles-Saint-Quentin-en-Yvelines, Boulogne-Billancourt, France.,INSERM Unit 1018, CESP, University Paris-Saclay, University of Versailles-Saint-Quentin-en-Yvelines, Université Paris Sud, Villejuif, France
| | - Kitty J Jager
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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11
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Hull KL, March DS, Churchward DR, Graham‐Brown MP, Burton JO. The effect of extended‐hours hemodialysis on outcomes: A systematic review and meta‐analysis. Hemodial Int 2020; 24:133-147. [DOI: 10.1111/hdi.12828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/05/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katherine L. Hull
- Department of Cardiovascular SciencesUniversity of Leicester Leicester UK
- John Walls Renal UnitLeicester General Hospital Leicester UK
| | - Daniel S. March
- Department of Cardiovascular SciencesUniversity of Leicester Leicester UK
- John Walls Renal UnitLeicester General Hospital Leicester UK
| | - Darren R. Churchward
- Department of Cardiovascular SciencesUniversity of Leicester Leicester UK
- John Walls Renal UnitLeicester General Hospital Leicester UK
| | - Matthew P.M. Graham‐Brown
- Department of Cardiovascular SciencesUniversity of Leicester Leicester UK
- John Walls Renal UnitLeicester General Hospital Leicester UK
| | - James O. Burton
- Department of Cardiovascular SciencesUniversity of Leicester Leicester UK
- John Walls Renal UnitLeicester General Hospital Leicester UK
- School of Sport, Exercise and Health SciencesLoughborough University Loughborough UK
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12
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Auguste BL, Girsberger M, Kennedy C, Srithongkul T, McGrath-Chong M, Bargman J, Chan CT. Are adverse events in newly trained home dialysis patients related to learning styles? A single-centre retrospective study from Toronto, Canada. BMJ Open 2020; 10:e033315. [PMID: 31964671 PMCID: PMC7045245 DOI: 10.1136/bmjopen-2019-033315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Home haemodialysis (HD) and peritoneal dialysis (PD) have seen growth in utilisation around the globe over the last few years. However, home dialysis, with its attendant technical complexity and risk of adverse events continues to pose challenges for wider adoption. We examined whether differences in patients' learning styles are associated with differing risk of adverse events in both home HD and PD patients. DESIGN Retrospective cohort study. SETTING Tertiary care hospital in Toronto, Ontario, Canada. PARTICIPANTS One hundred and eighteen prevalent adult (≥18 years) home dialysis patients (40 PD and 78 home HD) were enrolled. Patients on home dialysis for less than 6 months or receiving home nursing assistance for dialysis were excluded from the study. INTERVENTIONS Enrolled patients completed (VARK) Visual, Aural, Reading-writing and Kinesthetic questionnaires to determine learning styles. PRIMARY AND SECONDARY OUTCOME MEASURES Home HD and PD adverse events were identified within 6 months of completing home dialysis training. Event rates were then stratified and compared according to learning styles. RESULTS Thirty patients had a total of 53 adverse events. We used logistic regression analysis to determine unadjusted and adjusted ORs for a single adverse event. Non-visual learners were 4.35 times more likely to have an adverse event (p=0.001). After adjusting for age, gender, dialysis modality, training duration, dialysis vintage, prior renal replacement therapy, visual impairment, education and literacy, an adverse event was still four times more likely among non-visual learners compared to visual learners (p=0.008). A subgroup analysis of home HD patients showed adverse events were more likely among non-visual learners (OR 11.1; p=0.003), whereas PD patients showed a trend for more adverse events in non-visual learners (OR: 1.60; p=0.694). CONCLUSIONS Different learning styles in home dialysis patients exist. Visual learning styles are associated with fewer adverse events in home dialysis patients within the first 6 months of completing training. Individualisation of home dialysis training by learning style is warranted.
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Affiliation(s)
- Bourne Lewis Auguste
- Medicine; Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Medicine; Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Michael Girsberger
- Medicine; Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Claire Kennedy
- Medicine; Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | | | | | - Joanne Bargman
- Medicine; Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Medicine; Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Christopher T Chan
- Medicine; Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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13
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Gangaram V, Vilpakka M, Goffin E, Weinhandl ED, Kubisiak KM, Borman N. Nocturnal home hemodialysis with low-flow dialysate: Retrospective analysis of the first European patients. Hemodial Int 2019; 24:175-181. [PMID: 31820557 DOI: 10.1111/hdi.12808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/31/2019] [Accepted: 11/23/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Despite mounting evidence that increased frequency and duration of hemodialysis (HD) improves outcomes, less than 1% of HD patients worldwide receive nocturnal hemodialysis (NHD). Many perceived barriers exist to providing NHD and increasing its provision. METHODS A retrospective analysis of nocturnal therapy using a low-flow dialysate system in 4 European centers for a minimum of 12 months, with data collected on patient demographics, training times, safety features, medications, and biochemical parameters at baseline and at 6 and 12 months. FINDINGS Data were collected on 21 patients, with 12-month analysis available for 20 patients. Mean dialysis duration was 28 hours per week, with most dialysis on an alternate night regimen using 50-60 L of dialysate per session. All vascular access types were represented, and low molecular weight heparin was used as a bolus. All biochemical parameters met European standards, with a trend for improvement in standardized Kt/V, phosphate, hemoglobin, and albumin. There was a significant reduction in phosphate binder usage and a reduction in blood pressure medication. Training time was 9.6 sessions for independence at home, with 2 additional sessions to transition to NHD. Additional safety features included an alarmed drip tray under the cycler and moisture sensors under the venous needle (all patients used dual-cannulation technique). No patient safety events were reported. DISCUSSION These data support the use of a low-flow dialysate system for provision of NHD at home. Biochemical parameters were good, medication burden was reduced at 12 months, and all patients received more than double the duration of HD provided in standard in-center units. While patient numbers were small, low-flow dialysis in this cohort was both effective and safe. Use of this alternative HD system could reduce some of the barriers to NHD, increasing the uptake of therapy in Europe, and improving long-term patient outcomes.
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Affiliation(s)
- Venkat Gangaram
- Queen Alexandra Hospital, Wessex Kidney Centre, Portsmouth, UK
| | | | - Eric Goffin
- Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Eric D Weinhandl
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | | | - Natalie Borman
- Queen Alexandra Hospital, Wessex Kidney Centre, Portsmouth, UK
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14
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Hojs N, Fissell WH, Roy S. Ambulatory Hemodialysis-Technology Landscape and Potential for Patient-Centered Treatment. Clin J Am Soc Nephrol 2019; 15:152-159. [PMID: 31727617 PMCID: PMC6946084 DOI: 10.2215/cjn.01970219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CKD is a worldwide health problem and the number of patients requiring kidney replacement therapy is rising. In the United States, most patients with ESKD rely on in-center hemodialysis, which is burdensome and does not provide the same long-term benefits as kidney transplantation. Intensive hemodialysis treatments have demonstrated improved clinical outcomes, but its wider adoption is limited by equipment complexity and patient apprehension. Ambulatory devices for hemodialysis offer the potential for self-care treatment outside the clinical setting as well as frequent and prolonged sessions. This article explains the motivation for ambulatory hemodialysis and provides an overview of the necessary features of key technologies that will be the basis for new wearable and implantable devices. Early work by pioneers of hemodialysis is described followed by recent experience using a wearable unit on patients. Finally, ongoing efforts to develop an implantable device for kidney replacement and its potential for implantable hemodialysis are presented.
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Affiliation(s)
- Nina Hojs
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California, San Francisco, San Francisco, California.,Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia; and
| | - William H Fissell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shuvo Roy
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California, San Francisco, San Francisco, California;
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15
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Choo SZ, Polkinghorne KR, Kerr PG. Biochemical comparison of 8 h haemodialysis and 4 h haemodiafiltration, and two dialysis membranes, in a randomized cross-over trial. Nephrology (Carlton) 2019; 24:542-549. [PMID: 29722110 DOI: 10.1111/nep.13397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 11/28/2022]
Abstract
AIM Extended-hours haemodialysis has long been regarded as the optimal form of dialysis for solute clearance. With emerging benefits of haemodiafiltration, we wanted to compare these two head-to-head. METHODS In this randomized cross-over trial, we recruited existing nocturnal haemodialysis patients, who had not been hospitalized in the prior 3 months. After a baseline 8 h haemodialysis session, subjects were randomized to either 2 weeks of 8 h haemodialysis or 4 h haemodiafiltration with cross-over to the alternative treatment after a 2-week washout period. Subjects were additionally randomized to the Fresenius FX80 or Nipro Elisio in a parallel design. Blood and dialysate samples were collected at baseline and at the end of both study periods. RESULTS Twelve patients completed the study. Mean (SD) age and body mass index were 55.1 ± 11.5 years and 36.4 ± 10.8, respectively. Urea and creatinine reduction ratios were higher with extended-hours haemodialysis compared to haemodiafiltration (difference 14.0%, 95% CI = 10.6, 17.3; P < 0.001 and 9.1%, 95% CI = 11.0, 7.2; P < 0.001). Fibroblast growth factor 23 (FGF23) clearance was superior with haemodiafiltration (difference 20.1%, 95% CI = 8.7, 31.6; P = 0.001). No difference was seen in reduction ratios for phosphate, retinol binding protein, alpha-1-microglobulin, beta-2-microglobulin and fetuin with both modalities. Compared to Nipro Elisio, Fresenius FX80 dialyser achieved higher beta-2-microglobulin clearance (Period 1: difference 7.8%, 95% CI = 1.3, 14.4; P = 0.02, Period 2:7.5%, 95% CI = 1.0, 14.1; P = 0.02). CONCLUSIONS Small solute clearance was superior with extended-hours haemodialysis while haemodiafiltration enhanced FGF23 clearance. Beta-2-microglobulin clearance was improved with Fresenius FX80 dialyser, but this difference is unlikely to be clinically significant.
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Affiliation(s)
- Shi Z Choo
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
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16
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Choo SZ, See EJ, Simmonds RE, Somerville CA, Agar JWM. Nocturnal home haemodialysis: The 17 years experience of a single Australian dialysis service. Nephrology (Carlton) 2019; 24:1050-1055. [DOI: 10.1111/nep.13524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Shi Z Choo
- Department of Renal MedicineBarwon Health Geelong Victoria Australia
| | - Emily J See
- School of MedicineUniversity of Melbourne Melbourne Victoria Australia
- Department of Intensive CareAustin Health Melbourne Victoria Australia
| | | | | | - John W M Agar
- Department of Renal MedicineBarwon Health Geelong Victoria Australia
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17
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Huang SHS, MacRae J, Ross D, Imtiaz R, Hollingsworth B, Nesrallah GE, Copland MA, McFarlane PA, Chan CT, Zimmerman D. Buttonhole versus Stepladder Cannulation for Home Hemodialysis: A Multicenter, Randomized, Pilot Trial. Clin J Am Soc Nephrol 2019; 14:403-410. [PMID: 30659057 PMCID: PMC6419275 DOI: 10.2215/cjn.08310718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Canadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented. RESULTS Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted. CONCLUSIONS We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.
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Affiliation(s)
- Shih-Han S. Huang
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Jennifer MacRae
- Department of Medicine, Division of Nephrology, Foothills Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Dana Ross
- Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rameez Imtiaz
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Brittany Hollingsworth
- Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gihad E. Nesrallah
- Faculty of Medicine, Division of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
| | - Michael A. Copland
- Department of Medicine, Division of Nephrology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
| | | | - Christopher T. Chan
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Deborah Zimmerman
- Ottawa Hospital, Ottawa, Ontario, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
- Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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18
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Health-related quality of life compared between kidney transplantation and nocturnal hemodialysis. PLoS One 2018; 13:e0204405. [PMID: 30235331 PMCID: PMC6147724 DOI: 10.1371/journal.pone.0204405] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Health-related quality of life (HRQOL) is an important outcome measure in patients with end-stage renal disease. HRQOL is assumed to improve with kidney transplantation and also with nocturnal hemodialysis compared to conventional hemodialysis. However, there is no evidence regarding HRQOL to support the optimal treatment choice for patients on nocturnal hemodialysis who hesitate opting for transplantation. We therefore compared HRQOL between patients who were treated with kidney transplantation or nocturnal hemodialysis for one year. Methods We assessed HQROL using the Kidney Disease Quality of Life–Short Form questionnaire in a cross-sectional sample of patients who were treated with kidney transplantation (n = 41) or nocturnal hemodialysis (n = 31) for one year. All patients on nocturnal hemodialysis were transplantation candidates. Using linear regression, we compared HRQOL between kidney transplantation and nocturnal hemodialysis, and adjusted for age, sex, dialysis duration, cardiovascular disease, and presence of residual urine production. Results At one year follow-up, mean age of the study population was 54 ±13 years, and median dialysis duration was 3.2 (IQR 2.1–5.0) years. Kidney transplantation was associated with significantly higher HRQOL on the domain “effects” compared to nocturnal hemodialysis (adjusted difference 12.0 points, 95% CI 3.9; 20.1). There were potentially clinically relevant differences between kidney transplantation and nocturnal hemodialysis on the domains “burden” (adjusted difference 11.1 points, 95% CI -2.6; 24.8), “social support” (adjusted difference 6.2, 95% CI -6.6; 19.1), and the physical composite score (adjusted difference 3.0, 95% CI -2.0; 8.1), but these were not significant. Conclusions After kidney transplantation, HRQOL is especially higher on the domain “effects of kidney disease” compared to nocturnal hemodialysis. This can be useful when counseling patients on nocturnal hemodialysis who may opt for transplantation.
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19
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Abstract
The use of frequent hemodialysis (HD) is growing, with the hope of improving outcomes in end-stage renal disease. We narratively review the three randomized trials, 15 comparative cohort studies, and several case series of frequent HD that empirically demonstrate the potential efficacy and adverse effects of these regimens. Taken together, the randomized studies suggest frequent HD may result in left ventricular mass regression. This effect is most pronounced when left ventricular mass is abnormal, but attenuated by significant residual urine output. Both frequent short and long HD consistently improved blood pressure control and reduced antihypertensive use, despite greater weekly interdialytic weight gains. Serum phosphate was lowered. Frequent short daytime HD improved health-related quality of life, while frequent long overnight HD did not. Regarding adverse effects, frequent HD patients underwent significantly more procedures to salvage arteriovenous vascular accesses. An absolute increase in hypotensive episodes was observed with frequent short HD, while frequent long HD accelerated residual renal function loss and increased perceived caregiver burden. The effect of frequent HD on mortality is controversial, due to conflicting results and limitations of published studies. Finally, pregnancy outcomes may be substantially better with frequent long HD. On the basis of these data, we suggest frequent HD is most likely to benefit patients with left ventricular hypertrophy particularly if there is minimal urine output, those unable to attain dry weight on a thrice weekly schedule, and pregnant women. All patients receiving frequent HD should be advised of and monitored for potential risks.
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Affiliation(s)
- Rita S Suri
- Department of Medicine, University of Montreal, Montreal, Canada
| | - Alan S Kliger
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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20
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Brunati CCM, Gervasi F, Casati C, Querques ML, Montoli A, Colussi G. Phosphate and Calcium Control in Short Frequent Hemodialysis with the NxStage System One Cycler: Mass Balance Studies and Comparison with Standard Thrice-Weekly Bicarbonate Dialysis. Blood Purif 2018; 45:334-342. [PMID: 29455202 DOI: 10.1159/000487123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/25/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Short frequent dialysis with NxStage System One cycler (NSO) has become increasingly popular as home hemodialysis prescription. Short dialysis sessions with NSO might not allow adequate phosphate (P) removal. METHODS Single-session and weekly balances of P and calcium (Ca) were compared in 14 patients treated with NSO (6 sessions/week) and in 14 patients on standard bicarbonate dialysis (BHD). RESULTS NSO and BHD showed similar plasma P fall, with end-dialysis plasma P slightly lower in BHD (2.2 ± 0.5 vs. 2.7 ± 0.8 mg/dL, p < 0.02). Single-session P removal was lower in NSO, but weekly removal was higher (3,488 ± 1,181 mg vs. 2,634 ± 878, p < 0.003). Plasma Ca increase was lower in NSO, with similar PTH fall. Ca balance varied according to start plasma Ca, dialysate to blood Ca gradient and net ultrafiltration. CONCLUSIONS short, frequent home hemodialysis with NSO, on a 6/week-based prescription, allows higher weekly P removal than BHD. With the dialysate Ca concentration in use (6 mg/dL), total plasma Ca and iCa concentration increase is lower in NSO.
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Affiliation(s)
- Chiara Carla Maria Brunati
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Gervasi
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Nephrology School, Milano-Bicocca University, Milan, Italy
| | - Costanza Casati
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Luisa Querques
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alberto Montoli
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Colussi
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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21
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Abstract
Various modalities of high-intensity hemodialysis are gathering increasing popularity. Some of the advantages of these new dialysis regimens are presented. Time and the increasing use of these novel approaches will ultimately determine their role in the overall management of patients with end-stage renal disease.
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Affiliation(s)
- T. S. Ing
- Department of Medicine, Hines VA/Loyola University Medical Center, Hines, Illinois - USA
| | - C. Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
| | - C. R. Blagg
- Northwest Kidney Centers and University of Washington, Seattle, Washington - USA
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22
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Home Hemodialysis (HHD) Treatment as Effective yet Underutilized Treatment Modality in the United States. Healthcare (Basel) 2017; 5:healthcare5040090. [PMID: 29182543 PMCID: PMC5746724 DOI: 10.3390/healthcare5040090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/09/2017] [Accepted: 11/17/2017] [Indexed: 11/17/2022] Open
Abstract
End-stage renal disease (ESRD) is a major health burden and its incidence has been increasing yearly reaching 120,000 cases in 2014. Home hemodialysis (HHD) is a treatment modality option that has been shown to contribute to numerous clinical benefits but is largely underutilized due to many contributing factors. The purpose of this review paper is to analyze the advantages and disadvantages of HHD and the reasons for its low utilization with a special focus on its socioeconomic impact as compared to facility hemodialysis. Key factors contributing to HHD underutilization are related to the reimbursement system of the facility and nephrologists as well as the underutilization of the pre-dialysis educational benefit. Based on this comprehensive review of the literature, we propose several suggestions which may contribute to the expansion of HHD treatment modality.
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23
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Walker RC, Marshall R, Howard K, Morton RL, Marshall MR. “Who matters most?”: Clinician perspectives of influence and recommendation on home dialysis uptake. Nephrology (Carlton) 2017; 22:977-984. [DOI: 10.1111/nep.12920] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/01/2016] [Accepted: 09/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Rachael C Walker
- Hawkes Bay District Health Board; Hastings New Zealand
- School of Public Health, Sydney Medical School; University of Sydney; Sydney Australia
| | - Roger Marshall
- Marketing Department, Faculty of Business; Auckland University of Technology; Auckland New Zealand
| | - Kirsten Howard
- School of Public Health, Sydney Medical School; University of Sydney; Sydney Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre; University of Sydney; Sydney Australia
| | - Mark R Marshall
- School of Medicine, Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
- Baxter Healthcare (Asia) Pte Ltd; Singapore
- Department of Renal Medicine; Counties Manukau Health; Auckland New Zealand
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24
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Pérez Alba A, Slon Roblero F, Castellano Gasch S, Bajo Rubio MA. Barriers for the development of home hemodialysis in Spain. Spanish nephrologists survey. Nefrologia 2017; 37:665-668. [PMID: 29122220 DOI: 10.1016/j.nefro.2017.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/19/2017] [Accepted: 02/20/2017] [Indexed: 11/19/2022] Open
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25
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Li JW, Wong JHS, Chak WL, Chau KF. Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate, clinical, and laboratory outcomes: A 1-year retrospective observation study. Hemodial Int 2017; 22:308-317. [PMID: 29044930 DOI: 10.1111/hdi.12616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed. METHODS A 1-year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin). FINDINGS NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age-adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77-20.99, P = 0.04). They consumed less aluminum-based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol2 /L2 , P < 0.01), with similar hemoglobin levels. DISCUSSION NHHD appeared to offer higher employment rate, lower dosage of aluminum-based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong.
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Affiliation(s)
- John Wing Li
- Renal Unit, Queen Elizabeth Hospital, Hong Kong, China
| | | | | | - Ka Foon Chau
- Renal Unit, Queen Elizabeth Hospital, Hong Kong, China
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Kitagawa M, Sada KE, Hinamoto N, Kimachi M, Yamamoto Y, Onishi Y, Fukuhara S. Shorter dialysis session length was not associated with lower mental health and physical functioning in elderly hemodialysis patients: Results from the Japan Dialysis Outcome and Practice Patterns Study (J-DOPPS). PLoS One 2017; 12:e0184019. [PMID: 28877202 PMCID: PMC5587338 DOI: 10.1371/journal.pone.0184019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023] Open
Abstract
Background Health-related quality of life (HRQOL) is often prioritized over long-term survival in elderly patients. Although a longer dialysis session length (DSL) has been shown to reduce mortality, its effects on improving the HRQOL are unknown. Methods Using data from the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS), patients aged ≥ 65 years on maintenance hemodialysis were enrolled. DSL was categorized as short (<210 minutes), medium (210–240 minutes), or long (>240 minutes). The primary outcomes were changes in mental health (ΔMH) and physical functioning (ΔPF) scores assessed using the Japanese version of SF-12, in one year. The differences in the ΔMH and ΔPF among the three groups were assessed via regression (beta) coefficients derived using a linear regression model. Results Of 1,187 patients at baseline, 319 (26.9%) had a short length, 686 (57.8%) a medium length, and 182 (15.3%) a long length. We assessed the ΔMH data from 793 patients and the ΔPF data from 738. No significant differences in the ΔMH were noted for the short or long groups compared with the medium group (score difference: 0.26, 95% confidence interval [CI]: -4.17 to 4.69 for short; score difference: -1.15, 95% CI: -6.17 to 3.86 for long). Similarly, no significant differences were noted for these groups versus the medium group in ΔPF either (score difference: -1.43, 95% CI: -6.73 to 3.87 for short; score difference: -1.71, 95% CI: -7.63 to 4.22 for long). Conclusions A shorter DSL might have no adverse effects on MH or PF for elderly patients.
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Affiliation(s)
- Masashi Kitagawa
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
- * E-mail:
| | - Ken-ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Norikazu Hinamoto
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Miho Kimachi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Yoshihiro Onishi
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Kyoto, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Fukushima, Japan
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Perl J, Na Y, Tennankore KK, Chan CT. Temporal Trends and Factors Associated with Home Hemodialysis Technique Survival in Canada. Clin J Am Soc Nephrol 2017; 12:1248-1258. [PMID: 28739576 PMCID: PMC5544522 DOI: 10.2215/cjn.13271216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/04/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The last 15 years has seen growth in home hemodialysis (HD) utilization in Canada owing to reports of improved outcomes relative to patients on conventional in-center HD. What effect growth has had on home HD technique and patient survival during this period is not known. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We compared the risk of home HD technique failure, mortality, and the composite outcome among three incident cohorts of patients on home HD in Canada: 1996-2002, 2003-2007, and 2008-2012. A multivariable piece-wise exponential model was used to evaluate all outcomes using inverse probability of treatment and censoring weights. RESULTS A total of 1869 incident patients on home HD were identified from the Canadian Organ Replacement Register. Relative to those treated between 2003 and 2007 (n=568), the risk of home HD technique failure was similar between patients treated between 1996 and 2002 (n=233; adjusted hazard ratio [AHR], 1.39; 95% confidence interval [95% CI], 0.78 to 2.46) but higher among incident patients on home HD treated between 2008 and 2012 (n=1068; AHR, 1.51; 95% CI, 1.06 to 2.15). Relative to patients treated between 2003 and 2007, adjusted mortality was similar among those treated between 2008 and 2012 (AHR, 0.83; 95% CI, 0.58 to 1.19) and those treated between 1996 and 2002 (AHR, 0.67; 95% CI, 0.38 to 1.21). The risk of the composite outcome of death and technique failure was similar across cohorts, as was the risk of receiving a kidney transplant. Increasing age, diabetes as a comorbidity, and smoking status were associated with an increased risk of death as well as the composite outcome. Medium-sized facilities had a lower risk of death, technique failure, and the composite outcome compared with larger facilities. CONCLUSIONS A higher risk of technique failure was seen in the most contemporary era. Further characterization of the risk factors for, and causes of technique failure is needed to develop strategies to improve patient retention on home HD.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology and
- The Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Ontario, Canada
| | | | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; and
| | - Christopher T. Chan
- Division of Nephrology, Department of Medicine, University of Toronto, University Health Network, Ontario, Canada
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Shah N, Reintjes F, Courtney M, Klarenbach SW, Ye F, Schick-Makaroff K, Jindal K, Pauly RP. Quality Assurance Audit of Technique Failure and 90-Day Mortality after Program Discharge in a Canadian Home Hemodialysis Program. Clin J Am Soc Nephrol 2017; 12:1259-1264. [PMID: 28739573 PMCID: PMC5544501 DOI: 10.2215/cjn.00140117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/25/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about patients exiting home hemodialysis. We sought to characterize the reasons, clinical characteristics, and pre-exit health care team interactions of patients on home hemodialysis who died or underwent modality conversion (negative disposition) compared with prevalent patients and those who were transplanted (positive disposition). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted an audit of all consecutive patients incident to home hemodialysis from January of 2010 to December of 2014 as part of ongoing quality assurance. Records were reviewed for the 6 months before exit, and vital statistics were assessed up to 90 days postexit. RESULTS Ninety-four patients completed training; 25 (27%) received a transplant, 11 (12%) died, and 23 (25%) were transferred to in-center hemodialysis. Compared with the positive disposition group, patients in the negative disposition group had a longer mean dialysis vintage (3.15 [SD=4.98] versus 1.06 [SD=1.16] years; P=0.003) and were performing conventional versus a more intensive hemodialysis prescription (23 of 34 versus 23 of 60; P<0.01). In the 6 months before exit, the negative disposition group had significantly more in-center respite dialysis sessions, had more and longer hospitalizations, and required more on-call care team support in terms of phone calls and drop-in visits (each P<0.05). The most common reason for modality conversion was medical instability in 15 of 23 (65%) followed by caregiver or care partner burnout in three of 23 (13%) each. The 90-day mortality among patients undergoing modality conversion was 26%. CONCLUSIONS Over a 6-year period, approximately one third of patients exited the program due to death or modality conversion. Patients who die or transfer to another modality have significantly higher health care resource utilization (e.g., hospitalization, respite treatments, nursing time, etc.).
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Affiliation(s)
- Nikhil Shah
- Division of Nephrology, Department of Medicine and
| | - Frances Reintjes
- Northern Alberta Renal Program, Alberta Health Services, Edmonton, Alberta, Canada; and
| | - Mark Courtney
- Division of Nephrology, Department of Medicine and
- Northern Alberta Renal Program, Alberta Health Services, Edmonton, Alberta, Canada; and
| | - Scott W. Klarenbach
- Division of Nephrology, Department of Medicine and
- Northern Alberta Renal Program, Alberta Health Services, Edmonton, Alberta, Canada; and
| | - Feng Ye
- Division of Nephrology, Department of Medicine and
- Alberta Kidney Disease Network, Edmonton, Alberta, Canada
| | | | - Kailash Jindal
- Division of Nephrology, Department of Medicine and
- Northern Alberta Renal Program, Alberta Health Services, Edmonton, Alberta, Canada; and
| | - Robert P. Pauly
- Division of Nephrology, Department of Medicine and
- Northern Alberta Renal Program, Alberta Health Services, Edmonton, Alberta, Canada; and
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29
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Frequent hemodialysis: history of the modality and assessment of outcomes. Pediatr Nephrol 2017; 32:1293-1300. [PMID: 28396942 DOI: 10.1007/s00467-017-3659-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
Abstract
About 660,000 individuals have end-stage renal disease in the USA, the vast majority of whom are receiving standard, in-center, thrice-weekly hemodialysis (HD). The morbidity and mortality among patients receiving standard HD remain unacceptably high. Studies conducted over the past two decades have provided a substantial amount of information on the advantages and drawbacks of providing more frequent HD treatment, either in-center or at home. In this article I summarize these studies, focusing special attention on the randomized, cross-over study assessing outcomes in children who received either frequent, in-center HD or traditional, thrice-weekly, in-center HD performed by Laskin et al. (Pediatr Nephrol doi: 10.1007/s00467-017-3656-x , 2017).
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Wong B, Collister D, Muneer M, Storie D, Courtney M, Lloyd A, Campbell S, Pauly RP. In-Center Nocturnal Hemodialysis Versus Conventional Hemodialysis: A Systematic Review of the Evidence. Am J Kidney Dis 2017; 70:218-234. [PMID: 28359656 DOI: 10.1053/j.ajkd.2017.01.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/03/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Owing to its longer treatment duration-up to 8 hours per dialysis treatment-in-center thrice-weekly nocturnal hemodialysis (HD) is receiving greater attention. To better understand the evidence for in-center nocturnal HD, we sought to systematically review the literature to determine the effects of in-center nocturnal HD versus conventional HD on clinically relevant outcomes. STUDY DESIGN We searched MEDLINE, Embase, Evidence-Based Medicine Reviews (EBMR), Web of Science, and Scopus from the earliest date in the database to November 2016. SETTING & POPULATION Adults receiving in-center nocturnal HD compared with those receiving conventional HD. SELECTION CRITERIA FOR STUDIES All quasi-experimental and observational studies were considered; randomized trials were sought but not found. PREDICTOR Nocturnal vs conventional in-center HD. OUTCOMES Indexes of blood pressure and left ventricular hypertrophy, markers of anemia, measures of bone mineral metabolism, nutrition, quality of life, sleep quality, episodes of intradialytic hypotension, hospitalization, and mortality. RESULTS Of 2,086 identified citations, 21 met the inclusion criteria, comprising a total of 1,165 in-center nocturnal HD patients and 15,865 conventional HD patients. Although there was substantial heterogeneity in reporting of outcomes, we pooled data for measures of blood pressure, anemia, and mineral metabolism. Though heterogeneity was generally high, in-center nocturnal HD was associated with improved systolic blood pressure (-3.18 [95% CI, -5.58 to -0.78) mm Hg, increased hemoglobin levels (0.53 [95% CI, 0.11-0.94] g/dL), and lower serum phosphate levels (-0.97 [95% CI, -1.48 to -0.46] mg/dL). LIMITATIONS No randomized trials have been conducted to address the clinical effects of in-center nocturnal HD. The quality of the observational literature contributing to the results of this review was generally poor to moderate. Confounded outcomes are a significant concern. Publication bias and outcome reporting bias remain possibilities. CONCLUSIONS Relative to conventional HD, in-center nocturnal HD was associated with improvements in several clinically relevant outcomes. Other benefits may not have been detected due to small sample sizes of included studies; no prespecified outcome was worse with in-center nocturnal HD.
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Affiliation(s)
- Ben Wong
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada; Headwaters Health Care Centre, Orangeville, ON, Canada.
| | | | - Maliha Muneer
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
| | - Dale Storie
- University of Alberta Libraries, Edmonton, AB, Canada
| | - Mark Courtney
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
| | - Anita Lloyd
- Alberta Kidney Disease Network, Edmonton, AB, Canada
| | | | - Robert P Pauly
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
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Garg AX, Suri RS, Eggers P, Finkelstein FO, Greene T, Kimmel PL, Kliger AS, Larive B, Lindsay RM, Pierratos A, Unruh M, Chertow GM. Patients receiving frequent hemodialysis have better health-related quality of life compared to patients receiving conventional hemodialysis. Kidney Int 2017; 91:746-754. [PMID: 28094031 DOI: 10.1016/j.kint.2016.10.033] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/19/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Abstract
Most patients with end-stage kidney disease value their health-related quality of life (HRQoL) and want to know how it will be affected by their dialysis modality. We extended the findings of two prior clinical trial reports to estimate the effects of frequent compared to conventional hemodialysis on additional measures of HRQoL. The Daily Trial randomly assigned 245 patients to receive frequent (six times per week) or conventional (three times per week) in-center hemodialysis. The Nocturnal Trial randomly assigned 87 patients to receive frequent nocturnal (six times per week) or conventional (three times per week) home hemodialysis. All patients were on conventional hemodialysis prior to randomization, with an average feeling thermometer score of 70 to 75 (a visual analog scale from 0 to 100 where 100 is perfect health), an average general health scale score of 40 to 47 (a score from 0 to 100 where 100 is perfect health), and an average dialysis session recovery time of 2 to 3 hours. Outcomes are reported as the between-treatment group differences in one-year change in HRQoL measures and analyzed using linear mixed effects models. After one year in the Daily Trial, patients assigned to frequent in-center hemodialysis reported a higher feeling thermometer score, better general health, and a shorter recovery time after a dialysis session compared to standard thrice-weekly dialysis. After one year in the Nocturnal Trial, patients assigned to frequent home hemodialysis also reported a shorter recovery time after a dialysis session, but no statistical difference in their feeling thermometer or general health scores compared to standard home dialysis schedules. Thus, patients receiving day or nocturnal hemodialysis on average recovered approximately one hour earlier from a frequent compared to conventional hemodialysis session. Patients treated in an in-center dialysis facility reported better HRQoL with frequent compared to conventional hemodialysis.
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Affiliation(s)
- Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.
| | - Rita S Suri
- Department of Medicine, Section of Nephrology, Centre de Recherche, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Paul Eggers
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Fredric O Finkelstein
- Yale School of Medicine and Yale New Haven Health System, New Haven, Connecticut, USA
| | - Tom Greene
- University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Paul L Kimmel
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alan S Kliger
- Yale School of Medicine and Yale New Haven Health System, New Haven, Connecticut, USA
| | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert M Lindsay
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | | | - Mark Unruh
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Nickel M, Rideout W, Shah N, Reintjes F, Chen JZ, Burrell R, Pauly RP. Estimating patient-borne water and electricity costs in home hemodialysis: a simulation. CMAJ Open 2017; 5:E61-E65. [PMID: 28401120 PMCID: PMC5378499 DOI: 10.9778/cmajo.20160108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Home hemodialysis is associated with lower costs to the health care system compared with conventional facility-based hemodialysis because of lower staffing and overhead costs, and by transferring the treatment cost of utilities (water and power) to the patient. The purpose of this study was to determine the utility costs of home hemodialysis and create a formula such that patients and renal programs can estimate the annual patient-borne costs involved with this type of treatment. METHODS Seven common combinations of treatment duration and dialysate flows were replicated 5 times using various combinations of home hemodialysis and reverse osmosis machines. Real-time utility (electricity and water) consumption was monitored during these simulations. A generic formula was developed to allow patients and programs to calculate a more precise estimate of utility costs based on individual combinations of dialysis intensity, frequency and utility costs unique to any patient. RESULTS Using typical 2014 utility costs for Edmonton, the most expensive prescription was for nocturnal home hemodialysis (8 h at 300 mL/min, 6 d/wk), which resulted in a utility cost of $1269 per year; the least expensive prescription was for conventional home hemodialysis (4 h at 500 mL/min, 3 d/wk), which cost $420 per year. Water consumption makes up most of this expense, with electricity accounting for only 12% of the cost. INTERPRETATION We show that a substantial cost burden is transferred to the patient on home hemodialysis, which would otherwise be borne by the renal program.
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Affiliation(s)
- Matthew Nickel
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Wes Rideout
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Nikhil Shah
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Frances Reintjes
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Justin Z Chen
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Robert Burrell
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Robert P Pauly
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
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Rivara MB, Adams SV, Kuttykrishnan S, Kalantar-Zadeh K, Arah OA, Cheung AK, Katz R, Molnar MZ, Ravel V, Soohoo M, Streja E, Himmelfarb J, Mehrotra R. Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal disease. Kidney Int 2016; 90:1312-1320. [PMID: 27555118 PMCID: PMC5123950 DOI: 10.1016/j.kint.2016.06.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/19/2016] [Accepted: 06/23/2016] [Indexed: 01/16/2023]
Abstract
Extended-hours hemodialysis offers substantially longer treatment time compared to conventional hemodialysis schedules and is associated with improved fluid and electrolyte control and favorable cardiac remodeling. However, whether extended-hours hemodialysis improves survival remains unclear. Therefore, we determined the association between extended-hours compared to conventional hemodialysis and the risk of all-cause mortality in a nationally representative cohort of patients initiating maintenance dialysis in the United States from 2007 to 2011. Survival analyses using causal inference modeling with marginal structural models were performed to compare mortality risk among 1206 individuals undergoing thrice weekly extended-hours hemodialysis or 111,707 patients receiving conventional hemodialysis treatments. The average treatment time per session for extended-hours hemodialysis was 399 minutes compared to 211 minutes for conventional therapy. The crude mortality rate with extended-hours hemodialysis was 6.4 deaths per 100 patient-years compared with 14.7 deaths per 100 patient-years for conventional hemodialysis. In the primary analysis, patients treated with extended-hours hemodialysis had a 33% lower adjusted risk of death compared to those who were treated with a conventional regimen (95% confidence interval: 7% to 51%). Additional analyses accounting for analytical assumptions regarding exposure and outcome, facility-level confounders, and prior modality history were similar. Thus, in this large nationally representative cohort, treatment with extended-hours hemodialysis was associated with a lower risk for mortality compared to treatment with conventional in-center therapy. Adequately powered randomized clinical trials comparing extended-hours to conventional hemodialysis are required to confirm these findings.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.
| | - Scott V Adams
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sooraj Kuttykrishnan
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Onyebuchi A Arah
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA; UCLA Center for Health Policy Research, Los Angeles, California, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Ronit Katz
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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Torigoe A, Sato E, Mori T, Ieiri N, Takahashi C, Ishida Y, Hotta O, Ito S. Comparisons of amino acids, body constituents and antioxidative response between long-time HD and normal HD. Hemodial Int 2016; 20 Suppl 1:S17-S24. [PMID: 27669544 DOI: 10.1111/hdi.12462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction Oxidative stress is one of the main mediators of progression of chronic kidney diseases (CKD). Nuclear factor E2-related factor 2 (Nrf2) is the transcription factor of antioxidant and detoxifying enzymes and related proteins which play an important role in cellular defense. Long-time hemodialysis (HD) therapy (8 hours) has been considered to be more beneficial compared to normal HD therapy (4 hours). We investigated oxidative response related to Nrf2 in peripheral blood mononuclear cells (PBMCs) of long-time HD and normal HD patients. Methods Eight adult long-time HD therapy patients (44.5 ± 3.0 years) and 10 normal HD therapy patients (68.1 ± 2.7 years) were enrolled. PBMCs were isolated and processed for expression of Nrf2 and its related genes by qRT-PCR. Plasma indoxyl sulfate, amino acids, and body constituents were measured. Findings Plasma indoxyl sulfate was significantly low after long-time HD therapy compare to that of normal HD therapy. Although, skeletal muscle mass, lean body mass, mineral and protein were significantly decreased 2 months in normal HD patients, those in long-time HD patients were significantly increased after 2 months. Almost of amino acids were significantly decreased after HD therapy in both HD therapies. Plasma amino acids were significantly low in long-time HD patients compared to normal HD patients. In PBMCs, the expression of Nrf2 was significantly decreased and hemooxygenase-1 expression was significantly increased in long-time HD compared to normal HD. Conclusion These observations indicate the beneficial effects of in long-time HD in improving oxidative stress in patients.
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Affiliation(s)
- Akira Torigoe
- Division of nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Hotta Osamu Clinic, Sendai, Japan
| | - Emiko Sato
- Division of nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Takefumi Mori
- Division of nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Chika Takahashi
- Division of nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoko Ishida
- Division of nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Sadayoshi Ito
- Division of nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Perl J, Kalim S, Wald R, Goldstein MB, Yan AT, Noori N, Kiaii M, Wenger J, Chan C, Thadhani RI, Karumanchi SA, Berg AH. Reduction of carbamylated albumin by extended hemodialysis. Hemodial Int 2016; 20:510-521. [PMID: 27329430 DOI: 10.1111/hdi.12435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction Among conventional hemodialysis (CHD) patients, carbamylated serum albumin (C-Alb) correlates with urea and amino acid deficiencies and is associated with mortality. We postulated that reduction of C-Alb by intensive HD may correlate with improvements in protein metabolism and cardiac function. Methods One-year observational study of in-center nocturnal extended hemodialysis (EHD) patients and CHD control subjects. Thirty-three patients receiving 4-hour CHD who converted to 8-hour EHD were enrolled, along with 20 controls on CHD. Serum C-Alb, biochemistries, and cardiac MRI parameters were measured before and after 12 months of EHD. Findings EHD was associated with reduction of C-Alb (average EHD change -3.20 mmol/mol [95% CI -4.23, -2.17] compared to +0.21 [95% CI -1.11, 1.54] change in CHD controls, P < 0.001). EHD was also associated with increases in average essential amino acids (in standardized units) compared to CHD (+0.38 [0.08, 0.68 95%CI]) vs. -0.12 [-0.50, 0.27, 95% CI], P = 0.047). Subjects who reduced C-Alb more than 25% were found to have reduced left ventricular mass, increased urea reduction ratio, and increased serum albumin compared to nonresponders, and % change in C-Alb significantly correlated with % change in left ventricular mass. Discussion EHD was associated with reduction of C-Alb as compared to CHD, and reduction of C-Alb by EHD correlates with reduction of urea. Additional studies are needed to test whether reduction of C-Alb by EHD also correlates with improved clinical outcomes.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Sahir Kalim
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ron Wald
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc B Goldstein
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- Division of Cardiology, Department of Medicine, Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Nazanin Noori
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julia Wenger
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Chan
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - S Ananth Karumanchi
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anders H Berg
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School.
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36
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Ipema KJR, Struijk S, van der Velden A, Westerhuis R, van der Schans CP, Gaillard CAJM, Krijnen WP, Franssen CFM. Nutritional Status in Nocturnal Hemodialysis Patients - A Systematic Review with Meta-Analysis. PLoS One 2016; 11:e0157621. [PMID: 27322616 PMCID: PMC4913934 DOI: 10.1371/journal.pone.0157621] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background Hemodialysis patients experience an elevated risk of malnutrition associated with increased morbidity and mortality. Nocturnal hemodialysis (NHD) results in more effective removal of waste products and fluids. Therefore, diet and fluid restrictions are less restricted in NHD patients. However, it is ambiguous whether transition from conventional hemodialysis (CHD) to NHD leads to improved intake and nutritional status. We studied the effect of NHD on protein intake, laboratory indices of nutritional status, and body composition. Study design Systematic review with meta-analysis. Population NHD patients. Search strategy Systematic literature search from databases, Medline, Cinahl, EMBASE and The Cochrane Library, to identify studies reporting on nutritional status post-transition from CHD to NHD. Intervention Transition from CHD to NHD. Outcomes Albumin, normalized protein catabolic rate (nPCR), dry body weight (DBW), body mass index (BMI), phase angle, protein intake, and energy intake. Results Systematic literature search revealed 13 studies comprising 282 patients that made the transition from CHD to NHD. Meta-analysis included nine studies in 229 patients. In control group controlled studies (n = 4), serum albumin increased significantly from baseline to 4–6 months in NHD patients compared with patients that remained on CHD (mean difference 1.3 g/l, 95% CI 0.02; 2.58, p = 0.05). In baseline controlled studies, from baseline to 4–6 months of NHD treatment, significant increases were ascertained in serum albumin (mean difference (MD) 1.63 g/l, 95% CI 0.73–2.53, p<0.001); nPCR (MD 0.16 g/kg/day; 95% CI 0.04–0.29, p = 0.01); protein intake (MD 18.9 g, 95% CI 9.7–28.2, p<0.001); and energy intake (MD 183.2 kcal, 95% CI 16.8–349.7, p = 0.03). Homogeneity was rejected only for nPCR (baseline versus 4–6 months). DBW, BMI, and phase angle did not significantly change. Similar results were obtained for comparison between baseline and 8–12 months of NHD treatment. Limitations Most studies had moderate sample sizes; some had incomplete dietary records and relatively brief follow-up period. Studies markedly differed with regard to study design. Conclusions NHD is associated with significantly higher protein and energy intake as well as increases in serum albumin and nPCR. However, the data on body composition are inconclusive.
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Affiliation(s)
- Karin J. R. Ipema
- Dialysis Center Groningen, Groningen, The Netherlands
- Research group Healthy Ageing, Allied Health Care and Nursing, Hanze University Groningen, University of Applied Sciences, Groningen, the Netherlands
- * E-mail:
| | - Simone Struijk
- Research group Healthy Ageing, Allied Health Care and Nursing, Hanze University Groningen, University of Applied Sciences, Groningen, the Netherlands
| | - Annet van der Velden
- Research group Healthy Ageing, Allied Health Care and Nursing, Hanze University Groningen, University of Applied Sciences, Groningen, the Netherlands
| | - Ralf Westerhuis
- Dialysis Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cees P. van der Schans
- Research group Healthy Ageing, Allied Health Care and Nursing, Hanze University Groningen, University of Applied Sciences, Groningen, the Netherlands
- Department of Rehabilitation Medicine, Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carlo A. J. M. Gaillard
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wim P. Krijnen
- Research group Healthy Ageing, Allied Health Care and Nursing, Hanze University Groningen, University of Applied Sciences, Groningen, the Netherlands
| | - Casper F. M. Franssen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Gura V, Rivara MB, Bieber S, Munshi R, Smith NC, Linke L, Kundzins J, Beizai M, Ezon C, Kessler L, Himmelfarb J. A wearable artificial kidney for patients with end-stage renal disease. JCI Insight 2016; 1:86397. [PMID: 27398407 DOI: 10.1172/jci.insight.86397] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stationary hemodialysis machines hinder mobility and limit activities of daily life during dialysis treatments. New hemodialysis technologies are needed to improve patient autonomy and enhance quality of life. METHODS We conducted a FDA-approved human trial of a wearable artificial kidney, a miniaturized, wearable hemodialysis machine, based on dialysate-regenerating sorbent technology. We aimed to determine the efficacy of the wearable artificial kidney in achieving solute, electrolyte, and volume homeostasis in up to 10 subjects over 24 hours. RESULTS During the study, all subjects remained hemodynamically stable, and there were no serious adverse events. Serum electrolytes and hemoglobin remained stable over the treatment period for all subjects. Fluid removal was consistent with prescribed ultrafiltration rates. Mean blood flow was 42 ± 24 ml/min, and mean dialysate flow was 43 ± 20 ml/min. Mean urea, creatinine, and phosphorus clearances over 24 hours were 17 ± 10, 16 ± 8, and 15 ± 9 ml/min, respectively. Mean β2-microglobulin clearance was 5 ± 4 ml/min. Of 7 enrolled subjects, 5 completed the planned 24 hours of study treatment. The trial was stopped after the seventh subject due to device-related technical problems, including excessive carbon dioxide bubbles in the dialysate circuit and variable blood and dialysate flows. CONCLUSION Treatment with the wearable artificial kidney was well tolerated and resulted in effective uremic solute clearance and maintenance of electrolyte and fluid homeostasis. These results serve as proof of concept that, after redesign to overcome observed technical problems, a wearable artificial kidney can be developed as a viable novel alternative dialysis technology. TRIAL REGISTRATION ClinicalTrials.gov NCT02280005. FUNDING The Wearable Artificial Kidney Foundation and Blood Purification Technologies Inc.
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Affiliation(s)
- Victor Gura
- Cedars-Sinai Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine at UCLA, UCLA, Los Angeles, California, USA
| | - Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Scott Bieber
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Raj Munshi
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington, USA
| | - Nancy Colobong Smith
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,University of Washington Medical Center, Seattle, Washington, USA
| | - Lori Linke
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - John Kundzins
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Masoud Beizai
- Blood Purification Technologies Inc., Beverly Hills, California, USA
| | - Carlos Ezon
- Blood Purification Technologies Inc., Beverly Hills, California, USA
| | - Larry Kessler
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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Shen JI, Lum EL, Chang TI. Balancing the Evidence: How to Reconcile the Results of Observational Studies vs. Randomized Clinical Trials in Dialysis. Semin Dial 2016; 29:342-6. [PMID: 27207819 DOI: 10.1111/sdi.12518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Because large randomized clinical trials (RCTs) in dialysis have been relatively scarce, evidence-based dialysis care has depended heavily on the results of observational studies. However, when results from RCTs appear to contradict the findings of observational studies, nephrologists are left to wonder which type of study they should believe. In this editorial, we explore the key differences between observational studies and RCTs in the context of such seemingly conflicting studies in dialysis. Confounding is the major limitation of observational studies, whereas low statistical power and problems with external validity are more likely to limit the findings of RCTs. Differences in the specification of the population, exposure, and outcomes can also contribute to different results among RCTs and observational studies. Rigorous methods are required regardless of what type of study is conducted, and readers should not automatically assume that one type of study design is superior to the other. Ultimately, dialysis care requires both well-designed, well-conducted observational studies and RCTs to move the field forward.
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Affiliation(s)
- Jenny I Shen
- Department of Medicine, Division of Hypertension and Nephrology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California. .,Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Erik L Lum
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Tara I Chang
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
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39
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Rosenthal MM, Molzahn AE, Chan CT, Cockfield SL, Kim SJ, Pauly RP. Why take the chance? A qualitative grounded theory study of nocturnal haemodialysis recipients who decline kidney transplantation. BMJ Open 2016; 6:e011951. [PMID: 27194322 PMCID: PMC4874163 DOI: 10.1136/bmjopen-2016-011951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The objective of this study was to examine the factors that influence decision-making to forgo transplantation in favour of remaining on nocturnal haemodialysis (NHD). DESIGN A grounded theory approach using in-depth telephone interviewing was used. SETTING Participants were identified from 2 tertiary care renal programmes in Canada. PARTICIPANTS The study participants were otherwise eligible patients with end-stage renal disease who have opted to remain off of the transplant list. A total of 7 eligible participants were interviewed. 5 were male. The mean age was 46 years. ANALYSIS A constant comparative method of analysis was used to identify a core category and factors influencing the decision-making process. RESULTS In this grounded theory study of people receiving NHD who refused kidney transplantation, the core category of 'why take a chance when things are going well?' was identified, along with 4 factors that influenced the decision including 'negative past experience', 'feeling well on NHD', 'gaining autonomy' and 'responsibility'. CONCLUSIONS This study provides insight into patients' thought processes surrounding an important treatment decision. Such insights might help the renal team to better understand, and thereby respect, patient choice in a patient-centred care paradigm. Findings may also be useful in the development of education programmes addressing the specific concerns of this population of patients.
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Affiliation(s)
- Meagen M Rosenthal
- Department of Pharmacy Administration, University of Mississippi, Oxford, Mississippi, USA
| | - Anita E Molzahn
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sandra L Cockfield
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - S Joseph Kim
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert P Pauly
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
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40
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Daugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Suri RS, Weiner DE, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Slinin Y, Wilt TJ, Rocco M, Kramer H, Choi MJ, Samaniego-Picota M, Scheel PJ, Willis K, Joseph J, Brereton L. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis 2015; 66:884-930. [DOI: 10.1053/j.ajkd.2015.07.015] [Citation(s) in RCA: 603] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/31/2015] [Indexed: 12/13/2022]
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41
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Graham-Brown MPM, Churchward DR, Smith AC, Baines RJ, Burton JO. A 4-month programme of in-centre nocturnal haemodialysis was associated with improvements in patient outcomes. Clin Kidney J 2015; 8:789-95. [PMID: 26613041 PMCID: PMC4655800 DOI: 10.1093/ckj/sfv096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/03/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Extended periods of haemodialysis (HD) can improve patient outcomes. In-centre nocturnal haemodialysis (INHD) should be explored as a method of offering extended periods of HD to patients unsuitable for or unable to perform home therapy. METHODS Ten self-selecting, prevalent HD patients started an INHD programme to assess feasibility and patient satisfaction. Quality-of-life (QOL) measures were evaluated at enrolment and after 4 months of INHD using the EQ-5D, the Hospital Anxiety and Depression Scale (HADS) and the SF-12 questionnaires. Demographic, biochemical and haematological data and data on dialysis adequacy were collected before starting INHD and after 4 months. RESULTS Three of the 10 patients failed to complete the 2-week run-in period. Seven patients completed the 4-month programme, with mean dialysis time of 355 ± 43.92 min throughout the period. The EQ-5D visual analogue score improved from 48 ± 16.89 to 72 ± 13.2 (P = 0.003) and the HADS anxiety score decreased from 9 ± 5.83 to 3.57 ± 3.04 (P = 0.029). The urea reduction ratio improved from 71.57 ± 2.29% to 80.43 ± 3.101% (P < 0.001), with improvements in phosphate control, reducing to within the target range from 1.73 ± 0.6 to 1.2 ± 0.2 (P = 0.08). Ultrafiltration (UF) volumes increased during the study from 2000 ± 510 to 2606 ± 343 mL (P = 0.015); there was a significant reduction in mean UF rate adjusted for body weight from 6.47 ± 1.71 to 4.61 ± 1.59 mL/kg/h (P = 0.032). Sensitivity analyses confirmed the significance of these results. CONCLUSIONS This single-centre study showed a 4-month programme of extended hours INHD is safe and associated with improvements in QOL measures, decreased UF rates and measures of dialysis adequacy. These data have been used to expand our service and inform the design of future randomized controlled trials to examine medical endpoints.
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Affiliation(s)
- Matthew P M Graham-Brown
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - Darren R Churchward
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - Alice C Smith
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - Richard J Baines
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - James O Burton
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK ; Department of Cardiovascular Science , NIHR Leicester Cardiovascular Biomedical Research Unit , Leicester , UK
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42
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Kim DK, Lee JC, Lee H, Joo KW, Oh KH, Kim YS, Yoon HJ, Kim HC. Calculation of the clearance requirements for the development of a hemodialysis-based wearable artificial kidney. Hemodial Int 2015; 20:226-34. [PMID: 26245302 DOI: 10.1111/hdi.12343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Wearable artificial kidney (WAK) has been considered an alternative to standard hemodialysis (HD) for many years. Although various novel WAK systems have been recently developed for use in clinical applications, the target performance or standard dose of dialysis has not yet been determined. To calculate the appropriate clearance for a HD-based WAK system for the treatment of patients with end-stage renal disease with various dialysis conditions, a classic variable-volume two-compartment kinetic model was used to simulate an anuric patient with variable target time-averaged creatinine concentration (TAC), daily water intake volume, daily dialysis pause time, and patient body weight. A 70-kg anuric patient with a HD-based WAK system operating for 24 h required dialysis clearances of creatinine of at least 100, 50, and 25 mL/min to achieve TACs of 1.0, 2.0, and 4.0 mg/dL, respectively. The daily water intake volume did not affect the clearance required for dialysis under various conditions. As the pause time per day for the dialysis increased, higher dialysis clearances were required to maintain the target TAC. The present study provided theoretical dialysis doses for an HD-based WAK system to achieve various target TACs through relevant mathematical kinetic modeling. The theoretical results may contribute to the determination of the technical specifications required for the development of a WAK system.
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Affiliation(s)
- Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Kidney Research Institute, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Jung Chan Lee
- Department of Biomedical Engineering, Seoul National University Hospital, Seoul, South Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, South Korea.,Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Kidney Research Institute, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Kidney Research Institute, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Hyung-Jin Yoon
- Department of Biomedical Engineering, Seoul National University Hospital, Seoul, South Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, South Korea.,Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Hee Chan Kim
- Department of Biomedical Engineering, Seoul National University Hospital, Seoul, South Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, South Korea.,Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, South Korea
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43
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Lockridge R, Cornelis T, Van Eps C. Prescriptions for home hemodialysis. Hemodial Int 2015; 19 Suppl 1:S112-27. [DOI: 10.1111/hdi.12279] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Tom Cornelis
- Department of Internal Medicine; Division of Nephrology; Maastricht University Medical Center; Maastricht The Netherlands
| | - Carolyn Van Eps
- Princess Alexandra Hospital; Brisbane New South Wales Australia
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44
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Affiliation(s)
- John W. M. Agar
- Renal Unit; University Hospital; Barwon Health; Geelong Victoria Australia
| | - Dori Schatell
- CEO; Medical Education Institute; Madison Wisconsin USA
| | - Rachael Walker
- Nephrology; Hawkes Bay District Health Board; Hawkes Bay New Zealand
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45
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Tang X, Hu X, Mei C, Yu S. Improvement of Resistant Hypertension by Nocturnal Hemodialysis in a Patient with End-Stage Kidney Disease. Case Rep Nephrol Dial 2015; 5:60-5. [PMID: 25874195 PMCID: PMC4376926 DOI: 10.1159/000377671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Resistant hypertension is a common and refractory complication of hemodialysis (HD) patients and is associated with a higher risk of cardiovascular morbidity and mortality. Here we present a case of resistant hypertension treated successfully by nocturnal HD. A 63-year-old female with end-stage kidney disease was hospitalized for severe headache, objective vertigo and persistent vomiting for 1 month on February 6, 2012. She had been on intermittent HD for 3 months, and her blood pressure maintained 200–240/100–130 mm Hg even after using 7 kinds of antihypertensive drugs including olmesartan, benazepril, nitrendipine, arotinolol, terazosin, clonidine and torasemide. A CT of the abdomen revealed a mild hyperplasia of the left adrenal gland (fig. 1). However, plasma renin, angiotensin and aldosterone were all within the normal range. Nocturnal extended HD was initiated with a blood flow rate of 150 ml/min and a dialysis time of 7 h. After 3 months of nocturnal HD, all symptoms were relieved and her systolic blood pressure started to decrease by 10–20 mm Hg. Six months later, the predialysis blood pressure was decreased to 140–160/90–100 mm Hg and the antihypertensive drugs were reduced to 4 kinds. Meanwhile, the blood biochemical parameters including hemoglobin, serum calcium, phosphate and parathyroid hormone were all controlled well during 2 years of treatment. This case indicates that nocturnal extended HD is probably a promising and effective choice for resistant hypertension in HD patients.
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Affiliation(s)
| | | | | | - Shengqiang Yu
- *Shengqiang Yu, Division of Nephrology, Shanghai Changzheng Hospital, 415 Fengyang Rd, Huangpu District, Shanghai 200003 (PR China), E-Mail
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46
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Kotanko P, Garg AX, Depner T, Pierratos A, Chan CT, Levin NW, Greene T, Larive B, Beck GJ, Gassman J, Kliger AS, Stokes JB. Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials. Hemodial Int 2015; 19:386-401. [PMID: 25560227 DOI: 10.1111/hdi.12255] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypertension is a common complication of chronic kidney disease and persists among most patients with end-stage renal disease despite the provision of conventional thrice weekly hemodialysis (HD). We analyzed the effects of frequent HD on blood pressure in the randomized controlled Frequent Hemodialysis Network trials. The daily trial randomized 245 patients to 12 months of 6× ("frequent") vs. 3× ("conventional") weekly in-center hemodialysis; the nocturnal trial randomized 87 patients to 12 months of 6× weekly nocturnal HD vs. 3× weekly predominantly home-based hemodialysis. In the daily trial, compared with 3× weekly HD, 2 months of frequent HD lowered predialysis systolic blood pressure by -7.7 mmHg [95% confidence interval (CI): -11.9 to -3.5] and diastolic blood pressure by -3.9 mmHg [95% CI: -6.5 to -1.3]. In the nocturnal trial, compared with 3× weekly HD, 2 months of frequent HD lowered systolic blood pressure by -7.3 mmHg [95% CI: -14.2 to -0.3] and diastolic blood pressure by -4.2 mmHg [95% CI: -8.3 to -0.1]. In both trials, blood pressure treatment effects were sustained until month 12. Frequent HD resulted in significantly fewer antihypertensive medications (daily: -0.36 medications [95% CI: -0.65 to -0.08]; nocturnal: -0.44 mediations [95% CI: -0.89 to -0.03]). In the daily trial, the relative risk per dialysis session for intradialytic hypotension was lower with 6×/week HD but given the higher number of sessions per week, there was a higher relative risk for intradialytic hypotensive requiring saline administration. In summary, frequent HD reduces blood pressure and the number of prescribed antihypertensive medications.
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Affiliation(s)
- Peter Kotanko
- Renal Research Institute, New York City, New York, USA
| | - Amit X Garg
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Western University, London, Ontario, Canada
| | - Tom Depner
- Davis Medical Center, University of California Davis, Sacramento, California, USA
| | - Andreas Pierratos
- Humber River Regional Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA.,Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Alan S Kliger
- Department of Medicine, Hospital of Saint Raphael, Yale University School of Medicine, New Haven, Connecticut, USA
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Labriola L, Morelle J, Jadoul M. Con: Frequent haemodialysis for all chronic haemodialysis patients. Nephrol Dial Transplant 2014; 30:23-7. [PMID: 25538159 DOI: 10.1093/ndt/gfu382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Frequent haemodialysis (HD) regimens have been proposed with the aim to improve survival and other important patient outcomes. They indeed avoid the long interdialytic interval and have been associated with some proven benefits, i.e. an improvement in blood pressure and phosphataemia control, a reduction in left ventricular mass and lower ultrafiltration rates. However, the actual impact of frequent HD regimens on survival is, at best, inconclusive and, at worse, harmful, and remains uncertain regarding nutritional status and anaemia control. Moreover, the higher rates of vascular access complications and more rapid development of anuria with frequent HD regimens are worrying. Frequent HD also considerably increases the burden for patients and their caregivers, logistics and costs, especially with in-centre frequent schedules. In our opinion, before increasing HD frequency, a number of underused strategies summarized in our review and able to improve patient tolerance and/or HD dose should be tested first, taking into account patient's characteristics and life expectancy. Frequent HD schedules should be reserved for selected cases, only after all other available options have failed.
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Affiliation(s)
- Laura Labriola
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Johann Morelle
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Michel Jadoul
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Palmer SC, Palmer AR, Craig JC, Johnson DW, Stroumza P, Frantzen L, Leal M, Hoischen S, Hegbrant J, Strippoli GFM. Home versus in-centre haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2014; 2014:CD009535. [PMID: 25412074 PMCID: PMC7390476 DOI: 10.1002/14651858.cd009535.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Home haemodialysis is associated with improved survival and quality of life in uncontrolled studies. However, relative benefits and harms of home versus in-centre haemodialysis in randomised controlled trials (RCTs) are uncertain. OBJECTIVES To evaluate the benefits and harms of home haemodialysis versus in-centre haemodialysis in adults with end-stage kidney disease (ESKD). SEARCH METHODS The Cochrane Renal Group's Specialised Register was searched up to 31 October 2014. SELECTION CRITERIA RCTs of home versus in-centre haemodialysis in adults with ESKD were included. DATA COLLECTION AND ANALYSIS Data were extracted by two investigators independently. Study risk of bias and other patient-centred outcomes were extracted. Insufficient data were available to conduct meta-analyses. MAIN RESULTS We identified a single cross-over RCT (enrolling 9 participants) that compared home haemodialysis (long hours: 6 to 8 hours, 3 times/week) with in-centre haemodialysis (short hours: 3.5 to 4.5 hours, 3 times/weeks) for 8 weeks in prevalent home haemodialysis patients. Outcome data were limited and not available for the end of the first phase of treatment in this cross-over study which was at risk of bias due to differences in dialysate composition between the two treatment comparisons.Overall, home haemodialysis reduced 24 hour ambulatory blood pressure and improved uraemic symptoms, but increased treatment-related burden of disease and interference in social activities. Insufficient data were available for mortality, hospitalisation or dialysis vascular access complications or treatment durability. AUTHORS' CONCLUSIONS Insufficient randomised data were available to determine the effects of home haemodialysis on survival, hospitalisation, and quality of life compared with in-centre haemodialysis. Given the consistently observed benefits of home haemodialysis on quality of life and survival in uncontrolled studies, and the low prevalence of home haemodialysis globally, randomised studies evaluating home haemodialysis would help inform clinical practice and policy.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Andrew R Palmer
- Consorzio Mario Negri SudDepartment of Clinical Pharmacology and EpidemiologyVia Nationale 8/aMaria ImbaroItaly66030
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Paul Stroumza
- Diaverum MarseilleMedical OfficeRue Gaston BergerMarseilleFrance13010
| | - Luc Frantzen
- Diaverum MarseilleMedical OfficeRue Gaston BergerMarseilleFrance13010
| | - Miguel Leal
- Diaverum PortugalMedical OfficeSintra Business Park, Zona Industrial da AbrunheiraEdificio 4 ‐ Escritorio 2CSintraPortugal2710‐089
| | | | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- DiaverumMedical‐Scientific OfficeLundSweden
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Parker K, Nikam M, Jayanti A, Mitra S. Medication burden in CKD-5D: impact of dialysis modality and setting. Clin Kidney J 2014; 7:557-61. [PMID: 25859372 PMCID: PMC4389130 DOI: 10.1093/ckj/sfu091] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/11/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Medication adherence is thought to be around 50% in the general and dialysis population. Reducing the pill burden (PB) reduces regime complexity and can improve adherence. Increased adherence should lead to improvement in treatment outcomes and patient quality of life. There is currently little published data on PB in CKD-5D across dialysis modalities. METHODS This is a retrospective, single renal network study. All in-centre HD (MHD), peritoneal dialysis (PD) and home HD (HHD) patients were identified in the Greater Manchester East sector renal network. Information collected included age, sex, comorbidities, daily PB, dialysis vintage and adequacy. Data were retrieved from a customized renal database, clinic and discharge letters with cross validation from the general practitioner when needed. RESULTS Two hundred and thirty-six prevalent dialysis patients were studied. HHD patients had a significantly lower PB (11 ± 7 pills/day) compared with PD and MHD (16 ± 7 pills/day). The HHD patients required fewer BP medications to meet the recommended target. HD setting was the only significant factor for reducing PB. For home therapies (HHD versus PD), weekly Kt/v and serum phosphate were significant factors influencing PB. When comparing all modalities, OR of PB ≥ 15/day for MHD versus HHD was 3.9 and PD versus HHD was 4.9. The influence of HHD is dominant above factors such as comorbidities or clinical variables in reducing PB for MHD. Higher clearances achieved by HHD could explain differences in PB with PD. CONCLUSION This is the first comparative study of PB across all dialysis modalities and factors that influence it. The PB advantage in HHD may result in greater adherence and might contribute to the outcome benefit often seen with this modality. Higher clearances achieved by HHD could explain differences in PB with PD but the precise reasons for lower PB remain speculative and deserve further research in larger settings.
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Affiliation(s)
- Kathrine Parker
- Department of Nephrology , Manchester Institute of Nephrology and Transplantation , Manchester , UK
| | - Milind Nikam
- Department of Nephrology , Manchester Institute of Nephrology and Transplantation , Manchester , UK
| | - Anuradha Jayanti
- Department of Nephrology , Manchester Institute of Nephrology and Transplantation , Manchester , UK
| | - Sandip Mitra
- Department of Nephrology , Manchester Institute of Nephrology and Transplantation , Manchester , UK
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Enam N, Kakkad K, Amin A, Lever C. Management of hypertension in the hemodialysis population: a review of the literature. J Community Hosp Intern Med Perspect 2014; 4:24055. [PMID: 25147635 PMCID: PMC4120054 DOI: 10.3402/jchimp.v4.24055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/16/2014] [Accepted: 04/24/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The objective of this paper was to propose an algorithm for approaching hypertensive hemodialysis patients admitted to the hospital for hypertensive urgency. METHODS A literature search was conducted using PubMed (Medline). Articles selected were limited to humans and the English language. RESULTS WE IDENTIFIED EIGHT MANAGEMENT MODALITIES INCLUDING: short-daily and nocturnal dialysis, sodium restriction, sodium profiling, antihypertensive medications, sympathetic denervation, bilateral nephrectomy, and bioimpedance spectroscopy. The benefits and drawbacks of each were investigated and discussed before implementation into the algorithm. DISCUSSION The algorithm presented suggests a linear approach to patient care, but treatment modalities may not be mutually exclusive, and additional factors, such as patient compliance and individual health status, should be taken into account to provide patients with optimum care.
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Affiliation(s)
- Nabela Enam
- School of Medicine, University of Maryland, Baltimore, MD, USA
- Medstar Union Memorial Hospital, Baltimore, MD, USA
| | | | - Akshay Amin
- School of Medicine, University of Maryland, Baltimore, MD, USA
- Medstar Union Memorial Hospital, Baltimore, MD, USA
| | - Carole Lever
- Medstar Union Memorial Hospital, Baltimore, MD, USA
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