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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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2
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Rydell H, Ivarsson K, Almquist M, Clyne N, Segelmark M. Fewer hospitalizations and prolonged technique survival with home hemodialysis- a matched cohort study from the Swedish Renal Registry. BMC Nephrol 2019; 20:480. [PMID: 31888674 PMCID: PMC6937632 DOI: 10.1186/s12882-019-1644-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients on home hemodialysis (HHD) exhibit superior survival compared with patients on institutional hemodialysis (IHD) and peritoneal dialysis (PD). There is a sparsity of reports comparing morbidity between HHD and IHD or PD and none in a European population. The aim of this study is to compare morbidity between modalities in a Swedish population. METHODS The Swedish Renal Registry was used to retrieve patients starting on HHD, IHD or PD. Patients were matched according to sex, age, comorbidity and start date. The Swedish Inpatient Registry was used to determine comorbidity before starting renal replacement therapy (RRT) and hospital admissions during RRT. Dialysis technique survival was compared between HHD and PD. RESULTS RRT was initiated with HHD for 152 patients; these were matched with 608 patients with IHD and 456 with PD. Patients with HHD had significantly lower annual admission rate and number of days in hospital. (median 1.7 admissions; 12 days) compared with IHD (2.2; 14) and PD (2.8; 20). The annual admission rate was significantly lower for patients with HHD compared with IHD for cardiovascular diagnoses and compared with PD for infectious disease diagnoses. Dialysis technique survival was significantly longer with HHD compared with PD. CONCLUSIONS Patients choosing HHD as initial RRT spend less time in hospital compared with patients on IHD and PD and they were more likely than PD patients, to remain on their initial modality. These advantages, in combination with better survival and higher likelihood of renal transplantation, are important incentives for promoting the use of HHD.
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Affiliation(s)
- Helena Rydell
- Department of Clinical Sciences Lund, Nephrology, Lund University, Skane University Hospital, Njurmedicin exp A5:04, 171 76, Stockholm, Sweden.
| | - Kerstin Ivarsson
- Department of Clinical Sciences Lund, Nephrology, Lund University, Skane University Hospital, Njurmedicin exp A5:04, 171 76, Stockholm, Sweden
| | - Martin Almquist
- Department of Clinical Sciences Lund, Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Naomi Clyne
- Department of Clinical Sciences Lund, Nephrology, Lund University, Skane University Hospital, Njurmedicin exp A5:04, 171 76, Stockholm, Sweden
| | - Mårten Segelmark
- Department of Clinical Sciences Lund, Nephrology, Lund University, Skane University Hospital, Njurmedicin exp A5:04, 171 76, Stockholm, Sweden.,Department of Nephrology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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3
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Abstract
Conventional hemodialysis is associated with high morbidity and mortality rates, as well as a reduced quality of life. There is a growing interest in the provision of more intensive hemodialysis, due to associated benefits in terms of reduced cardiovascular morbidity, better regulation of mineral metabolism, as well as its impact on quality of life measures, fertility, and sleep. Nocturnal hemodialysis, both in center and at home, allows the delivery of more intensive hemodialysis. This review discusses the benefits of nocturnal hemodialysis and evaluates the evidence based on available literature.
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4
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Rydell H, Ivarsson K, Almquist M, Segelmark M, Clyne N. Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study. BMC Nephrol 2019; 20:52. [PMID: 30760251 PMCID: PMC6375181 DOI: 10.1186/s12882-019-1245-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/01/2019] [Indexed: 11/28/2022] Open
Abstract
Background The survival rate for dialysis patients is poor. Previous studies have shown improved survival with home hemodialysis (HHD), but this could be due to patient selection, since HHD patients tend to be younger and healthier. The aim of the present study is to analyse the long-term effects of HHD on patient survival and on subsequent renal transplantation, compared with institutional hemodialysis (IHD) and peritoneal dialysis (PD), taking age and comorbidity into account. Methods Patients starting HHD as initial renal replacement therapy (RRT) were matched with patients on IHD or PD, according to gender, age, Charlson Comorbidity Index and start date of RRT, using the Swedish Renal Registry from 1991 to 2012. Survival analyses were performed as intention-to-treat (disregarding changes in RRT) and per-protocol (as on initial RRT). Results A total of 152 patients with HHD as initial RRT were matched with 608 IHD and 456 PD patients, respectively. Median survival was longer for HHD in intention-to-treat analyses: 18.5 years compared with 11.9 for IHD (p < 0.001) and 15.0 for PD (p = 0.002). The difference remained significant in per-protocol analyses omitting the contribution of subsequent transplantation. Patients on HHD were more likely to receive a renal transplant compared with IHD and PD, although treatment modality did not affect subsequent graft survival (p > 0.05). Conclusion HHD as initial RRT showed improved long-term patient survival compared with IHD and PD. This survival advantage persisted after matching and adjusting for a higher transplantation rate. Dialysis modality had no impact on subsequent graft survival.
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Affiliation(s)
- Helena Rydell
- Department of Clinical Sciences Lund, University, Skane University Hospital, Nephrology Lund, Lund, Sweden.
| | - Kerstin Ivarsson
- Department of Clinical Sciences Lund, Pediatric psychiatry, Lund University, Skane University Hospital, Lund, Sweden
| | - Martin Almquist
- Department of Clinical Sciences, Lund University, Skane University Hospital Lund Surgery, Lund, Sweden
| | - Mårten Segelmark
- Department of Clinical Sciences Lund, University, Skane University Hospital, Nephrology Lund, Lund, Sweden
| | - Naomi Clyne
- Department of Clinical Sciences Lund, University, Skane University Hospital, Nephrology Lund, Lund, Sweden
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5
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Umeukeje EM, Mixon AS, Cavanaugh KL. Phosphate-control adherence in hemodialysis patients: current perspectives. Patient Prefer Adherence 2018; 12:1175-1191. [PMID: 30013329 PMCID: PMC6039061 DOI: 10.2147/ppa.s145648] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES This review summarizes factors relevant for adherence to phosphate-control strategies in dialysis patients, and discusses interventions to overcome related challenges. METHODS A literature search including the terms "phosphorus", "phosphorus control", "hemo-dialysis", "phosphate binder medications", "phosphorus diet", "adherence", and "nonadherence" was undertaken using PubMed, PsycInfo, CINAHL, and Embase. RESULTS Hyperphosphatemia is associated with cardiovascular and all-cause mortality in dialysis patients. Management of hyperphosphatemia depends on phosphate binder medication therapy, a low-phosphorus diet, and dialysis. Phosphate binder therapy is associated with a survival benefit. Dietary restriction is complex because of the need to maintain adequate protein intake and, alone, is insufficient for phosphorus control. Similarly, conventional hemodialysis alone is insufficient for phosphorus control due to the kinetics of dialytic phosphorus removal. Thus, all three treatment approaches are important contributors, with dietary restriction and dialysis as adjuncts to the requisite phosphate binder therapy. Phosphate-control adherence rates are suboptimal and are influenced directly by patient, provider, and phosphorus-control strategy-related factors. Psychosocial factors have been implicated as influential "drivers" of adherence behaviors in dialysis patients, and factors based on self-motivation associate directly with adherence behavior. Higher-risk subgroups of nonadherent patients include younger dialysis patients and non-whites. Provider attitudes may be important - yet unaddressed - determinants of adherence behaviors of dialysis patients. CONCLUSION Adherence to phosphate binders, low-phosphorus diet, and dialysis prescription is suboptimal. Multicomponent strategies that concurrently address therapy-related factors such as side effects, patient factors targeting self-motivation, and provider factors to improve attitudes and delivery of culturally sensitive care show the most promise for long-term control of phosphorus levels. Moreover, it will be important to identify patients at highest risk for lack of control, and for programs to be ready to deliver flexible person-centered strategies through training and dedicated resources to align with the needs of all patients.
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Affiliation(s)
- Ebele M Umeukeje
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA,
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville TN, USA,
- Vanderbilt Center for Health Services Research, Nashville, TN, USA,
| | - Amanda S Mixon
- Vanderbilt Center for Health Services Research, Nashville, TN, USA,
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kerri L Cavanaugh
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA,
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville TN, USA,
- Vanderbilt Center for Health Services Research, Nashville, TN, USA,
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6
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Mitsides N, Cornelis T, Broers NJH, Diederen NMP, Brenchley P, van der Sande FM, Schalkwijk C, Kooman JP, Mitra S. Cardiovascular and Patient Phenotype of Extended Haemodialysis: A Critical Analysis of Studying a Unique Patient Population. Blood Purif 2018; 45:356-363. [PMID: 29455200 DOI: 10.1159/000485231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/13/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extended haemodialysis (EHD) has been associated with better outcomes compared to conventional (CHD) regimes. The cardiovascular (CV) profile of these patients has not been assessed in detail. METHODS We report baseline demographic and CV phenotype of 36 CHD and 36 EHD participants to a longitudinal multicentre study. We measured pulse wave velocity (PWV), 24-h ambulatory blood pressure, sublingual dark-field capillaroscopy and vascular biomarkers. RESULTS EHD patients were younger (p < 0.01), with less CV comorbidity (p = 0.04) and higher dialysis vintage (p < 0.01). Higher PWV in CHD (p = 0.02) was not independent of demographic differences in the 2 groups. Biomarker profiles were similar in EHD and CHD but abnormal compared to healthy controls. CONCLUSION Although CV profiles in these 2 cohorts were similar, EHD patients were distinct from the CHD population in terms of age and dialysis vintage and appear to comprise a unique group. Direct comparison of outcomes in these groups is challenging due to clinical bias.
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Affiliation(s)
- Nicos Mitsides
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Department of Nephrology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,NIHR Devices for Dignity Healthcare Technology Co-Operative, Royal Hallamshire Hospital, Sheffield, Sheffield, United Kingdom
| | | | - Natascha J H Broers
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Nanda M P Diederen
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Paul Brenchley
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Department of Nephrology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Frank M van der Sande
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Casper Schalkwijk
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Sandip Mitra
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Department of Nephrology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,NIHR Devices for Dignity Healthcare Technology Co-Operative, Royal Hallamshire Hospital, Sheffield, Sheffield, United Kingdom
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7
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Mitsides N, Cornelis T, Broers NJH, Diederen NMP, Brenchley P, Heitink-Ter Braak N, van der Sande FM, Schalkwijk CG, Kooman JP, Mitra S. Inflammatory and Angiogenic Factors Linked to Longitudinal Microvascular Changes in Hemodialysis Patients Irrespective of Treatment Dose Intensity. Kidney Blood Press Res 2017; 42:905-918. [PMID: 29145197 DOI: 10.1159/000485048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/25/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease is a major contributor to the poor outcomes observed in hemodialysis. We investigated the relationship between hemodialysis intensity and vascular parameters in high-dose (HDHD; >12hrs/week) and Conventional (CHD; ≤12hrs/week) hemodialysis intensity over a 6-month period. METHODS We present the 6-month longitudinal analysis of a 2-year multicenter study investigating the effects of HDHD on cardiovascular parameters. We used pulse wave velocity, 24hr ambulatory blood pressure and sublingual dark field capillaroscopy measurements to assess macro- and microcirculation on 6-monthly basis. Pro-inflammatory and endothelial biomarkers were also measured at 6-monthly intervals. RESULTS 47 participants (21 HDHD, 26 CHD) were studied. CHD were older (63.5±14.2 vs 53.7±12.6 yr; p=0.018), with shorter dialysis vintage (median 23 vs 61 months; p=0.001). There was considerable variability in the degree and direction of change of circulatory measurements over a 6-month period. Hemodialysis intensity (hrs/week) did not correlate to these changes, when adjusted for age, dialysis vintage and comorbidity. Higher levels of Interleukin (IL)-8 measured at baseline independently predicted an increase in the Perfused Boundary Region (5-25μm) of the endothelial glycocalyx (p=0.010) whilst higher levels of soluble Flt-1 had a significant inverse effect (p=0.002) in an adjusted linear model. CONCLUSION Hemodialysis intensity did not predict changes in either macro- or microvascular parameters. Inflammation mediated through the IL-8 pathway predicted microvascular injury while Flt-1, a potential marker of angiogenesis and endothelial repair, might have a significant protective role. Further understanding of these pathways will be necessary to improve dialysis outcomes.
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Affiliation(s)
- Nicos Mitsides
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Nephrology Department, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,NIHR Devices for Dignity Healthcare Technology Co-operative, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - Natascha J H Broers
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Nanada M P Diederen
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Paul Brenchley
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Nephrology Department, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Nicole Heitink-Ter Braak
- Department of Internal Medicine, Division of Nephrology, Zuyderland Medical Center, Heerlen-Geleen, the Netherlands
| | - Frank M van der Sande
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Casper G Schalkwijk
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Sandip Mitra
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Nephrology Department, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,NIHR Devices for Dignity Healthcare Technology Co-operative, Royal Hallamshire Hospital, Sheffield, United Kingdom
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8
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Liu F, Sun Y, Xu T, Sun L, Liu L, Sun W, Feng X, Ma J, Wang L, Yao L. Effect of Nocturnal Hemodialysis versus Conventional Hemodialysis on End-Stage Renal Disease: A Meta-Analysis and Systematic Review. PLoS One 2017; 12:e0169203. [PMID: 28107451 PMCID: PMC5249197 DOI: 10.1371/journal.pone.0169203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/12/2016] [Indexed: 12/20/2022] Open
Abstract
Objectives The purpose of this study is to assess the efficacy and safety of nocturnal hemodialysis on end-stage renal disease (ESRD) patients. Methods We searched Medline, EmBase, and the Cochrance Central Register of Controlled Trials for studies up to January 2016. Analysis was done to compare variant outcomes of different hemodialysis schedules, including mortality, cardiovascular-associated variables, uremia-associated variables, quality of life (QOL), side-effects, and drug usage. Results We collected and analyzed the results of 28 studies involving 22,508 patients in our meta-analysis. The mortality results in this meta-analysis indicated that the nocturnal hemodialysis (NHD) group was not significantly different from conventional hemodialysis (CHD) group (Mortality: OR: 0.75; 95% confidence intervals (CIs): 0.52 to 1.10; p = 0.145), but the CHD group had significantly fewer number of hospitalizations than the NHD group (OR: 1.54; 95%CI: 1.32 to 1.79; p<0.001). NHD was superior to CHD for cardiovascular-associated (left ventricular hypertrophy [LVH]: SMD: -0.39; 95%CI: -0.68 to -0.10; p = 0.009, left ventricular hypertrophy index [LVHI]: SMD: -0.64; 95%CI: -0.83 to -0.46; p<0.001) and uremia-associated intervention results (Serum albumin: SMD: 0.89; 95%CI: 0.41 to 1.36; p<0.001). For the assessment of quality of life, NHD treatment significantly improved the patients’ QOL only for SF36-Physical Components Summary (SMD: 0.43; 95%CI: 0.26 to 0.60; p<0.001). NHD intervention was relatively better than CHD for anti-hypertensive drug usage (SMD: -0.48; 95%CI: -0.91 to -0.05; p = 0.005), and there was no difference between groups in our side-effects assessment. Conclusion NHD and CHD performed similarly in terms of ESRD patients’ mortality and side-effects. NHD was superior to CHD for cardiovascular-associated and uremia-associated results, QOL, and drug usage; for number of hospitalizations, CHD was relatively better than NHD.
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Affiliation(s)
- Fangjie Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yiting Sun
- Department of Clinical Medicine, China Medical University, Shenyang, Liaoning, China
| | - Tianhua Xu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Sun
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Linlin Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wei Sun
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xin Feng
- Blood Purification Center, Liaoning Electric Power Center Hospital, Shenyang, Liaoning, China
| | - Jianfei Ma
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Lining Wang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- * E-mail:
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9
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology; University Health Network; Toronto Ontario Canada
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10
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Molnar MZ, Ravel V, Streja E, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Racial Differences in Survival of Incident Home Hemodialysis and Kidney Transplant Patients. Transplantation 2016; 100:2203-10. [PMID: 26588010 PMCID: PMC4873468 DOI: 10.1097/tp.0000000000001005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous studies have indicated that patients on maintenance hemodialysis have worse survival compared with kidney transplant (KTx) recipients. However, none of these studies have compared mortality of the US patients using alternative dialysis modalities such as home hemodialysis (HHD) with KTx recipients. METHODS Comparing patients who started HHD with those who received kidney transplantation in the United States between 2007 and 2011, we created a 1:1 propensity score-matched cohort of 4000 patients and examined the association between treatment modality and all-cause mortality using Cox proportional hazard models. RESULTS The mean ± SD age of the propensity score-matched HHD and KTx patients at baseline were 54 ± 15 years and 54 ± 14 years, 65% were men (both groups), 70% and 72% of patients were whites, and 19% were African American (both groups), respectively. Over 5 years of follow-up, HHD patients had 4 times higher mortality risk compared with KTx recipients in the entire patient population (hazard ratio [HR], 4.06; 95% confidence interval [95% CI], 3.27-5.04); total event number, 411), and similar difference was found across each race stratum. However, during the first year of therapy, although the white HHD patients had higher mortality risk (HR, 4.21; 95% CI, 3.10-5.73; total event number, 332) compared with their KTx counterparts, there was no significant difference in mortality risk between African American HHD and KTx patients (HR, 1.62; 95% CI, 0.77-3.39; total event number, 55). This result was consistent across different types of kidney donors. CONCLUSIONS The HHD patients appear to have 4 times higher mortality compared with KTx recipients regardless of the type of kidney donor. Further studies are needed to understand the reasons underlying racial differenes during the first year of therapy.
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Affiliation(s)
- Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vanessa Ravel
- Division of Nephrology, University of California, Irvine, CA, USA
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA, USA
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Molnar MZ, Ravel V, Streja E, Kovesdy CP, Rivara MB, Mehrotra R, Kalantar-Zadeh K. Survival of Elderly Adults Undergoing Incident Home Hemodialysis and Kidney Transplantation. J Am Geriatr Soc 2016; 64:2003-2010. [PMID: 27612017 DOI: 10.1111/jgs.14321] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the mortality of elderly adults with end-stage renal disease (ESRD) treated with home hemodialysis (HD) with that of those receiving a kidney transplant (KTx). DESIGN Prospective cohort. SETTING Pertinent data for the two groups were obtained from electronic medical records from a large dialysis provider and the U.S. Renal Data System. PARTICIPANTS Using data from elderly adults (aged ≥65) who started home HD and underwent KTx in the US between 2007 and 2011, a 1:1 propensity score (PS)-matched cohort of 960 elderly adults was created, and the association between treatment modality and all-cause mortality was examined using Cox proportional hazards and competing risk regression survival models using modality failure as a competing event. MEASUREMENTS Modality of renal replacement therapy. RESULTS The baseline mean age ± standard deviation of the PS-matched individuals undergoing home HD was 71 ± 6, and that of KTx recipients was 71 ± 5, 69% of both groups were male, 81% of those undergoing home HD and 79% of KTx recipients were white, and 11% and 12%, respectively, were African American. Median follow-up time was 205 days (interquartile range (IQR) 78-364 days) for those undergoing home HD and 795 days (IQR 366-1,221 days) for KTx recipients. There were 97 deaths (20%, 253/1,000 patient-years, 95% confidence interval (CI) = 207-309/1,000 patient-years) in the home HD group and 48 deaths (10%, 45/1,000 patient-years, 95% CI = 34-60/1,000 patient-years) in the KTx group. Elderly adults undergoing home HD had a risk of mortality that was almost five times as high as that of KTx recipients (hazard ratio = 4.74, 95% CI = 3.25-6.91). Similar results were seen in competing risk regression analyses (subhazard ratio = 4.71, 95% CI = 3.27-6.79). Results were consistent across different types of kidney donors and subgroups divided according to various recipient characteristics. CONCLUSION Elderly adults with ESRD who receive a KTx have greater survival than those who undergo home HD. Further studies are needed to assess whether KTx receipt is associated with other benefits such as better quality of life and lower hospitalization rates.
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Affiliation(s)
- Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Vanessa Ravel
- Division of Nephrology, University of California, Irvine, California
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, California
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Matthew B Rivara
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Rajnish Mehrotra
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington
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12
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Mitsides N, Mitra S, Cornelis T. Clinical, patient-related, and economic outcomes of home-based high-dose hemodialysis versus conventional in-center hemodialysis. Int J Nephrol Renovasc Dis 2016; 9:151-9. [PMID: 27462173 PMCID: PMC4940011 DOI: 10.2147/ijnrd.s89411] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Despite technological advances in renal replacement therapy, the preservation of health and quality of life for individuals on dialysis still remains a challenge. The high morbidity and mortality in dialysis warrant further research and insight into the clinical domains of the technique and practice of this therapy. In the last 20 years, the focus of development in the field of hemodialysis (HD) has centered around adequate removal of urea and other associated toxins. High-dose HD offers an opportunity to improve mortality, morbidity, and quality of life of patients with end-stage kidney disease. However, the uptake of this modality is low, and the risk associated with the therapy is not fully understood. Recent studies have highlighted the evidence base and improved our understanding of this technique of dialysis. This article provides a review of high-dose and home HD, its clinical impact on patient outcome, and the controversies that exist.
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Affiliation(s)
- Nicos Mitsides
- Department of Renal Medicine, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Center, Manchester; National Institute for Healthcare Research Devices for Dignity Healthcare Co-operative, Sheffield, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Center, Manchester; National Institute for Healthcare Research Devices for Dignity Healthcare Co-operative, Sheffield, UK
| | - Tom Cornelis
- Department of Nephrology, Jessa Hospital, Hasselt, Belgium
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Auguste BL, Yuen D, Chan CT. Conventional hemodialysis is associated with greater bone loss than nocturnal hemodialysis: a retrospective observational study of a convenience cohort. Can J Kidney Health Dis 2016; 3:27. [PMID: 27252880 PMCID: PMC4888502 DOI: 10.1186/s40697-016-0118-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 04/19/2016] [Indexed: 04/18/2023] Open
Abstract
Background Compared with the general population, end-stage renal disease patients are at increased risk for bone loss and fractures. Nocturnal hemodialysis offers superior calcium-phosphate control and improved uremic clearance compared with conventional hemodialysis. Rates of bone loss by type of hemodialysis are unknown. Objectives This study aims to determine whether there are differences in bone loss between frequent nocturnal hemodialysis and conventional hemodialysis. Design This is a retrospective observational study. Setting Participants were selected from two teaching hospitals in downtown Toronto. Participants The study included 88 participants on dialysis for at least 6 months (52 patients on conventional hemodialysis and 36 patients converted from conventional hemodialysis to nocturnal hemodialysis). Patients on peritoneal dialysis and with previous renal transplants were excluded. Measurements We obtained demographic variables and biochemical data by a chart review. We examined changes in bone mineral density at the hip (femoral neck, total hip) and spine (L1 to L4) measured at baseline and about 1 year in the two groups. Methods We used Student’s t test for evaluation of between-group mean differences in demographic and biochemical parameters. We used linear regression models adjusted for baseline age, weight, dialysis vintage, markers of mineral metabolism (serum phosphate, serum calcium, and parathyroid hormone), and baseline bone mineral density at the femoral neck, total hip, and lumbar spine to determine the annualized percent change by hemodialysis type. Results Conventional hemodialysis subjects were older than nocturnal hemodialysis subjects (66 ± 9 vs 43 ± 10 years; p < 0.0001) with no significant differences in weight, dialysis vintage, serum phosphate, or parathyroid hormone between the two groups at baseline. In a period over 1 year, conventional hemodialysis compared to nocturnal hemodialysis subjects had significantly greater bone mineral density losses at all sites (1.6 % loss at the lumbar spine (95 % confidence interval (CI) 0.2–3.1), 1.3 % loss at the femoral neck (95 % CI 0.1–2.5), and 1.1 % loss at the total hip (95 % CI 0.1–2.6). Limitations Some limitations to this study are the lack of medication administration history, short duration (~1 year), and small sample sizes. Conclusions This is the first study comparing bone density between hemodialysis modalities. Our study demonstrates that bone loss is less in nocturnal hemodialysis compared to that in conventional hemodialysis which may result in less fractures. Larger observational studies are ultimately needed to confirm preliminary findings from our study.
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Affiliation(s)
- Bourne L Auguste
- Women's College Hospital, Department of Medicine, University of Toronto, 76 Grenville Avenue, Room 3426, Toronto, ON M5S 1B1 Canada
| | - Darren Yuen
- St. Michael's Hospital, Division of Nephrology, University of Toronto, Toronto, Canada
| | - Christopher T Chan
- Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Rocco MV. Chronic Hemodialysis Therapy in the West. KIDNEY DISEASES (BASEL, SWITZERLAND) 2015; 1:178-86. [PMID: 27536678 PMCID: PMC4934827 DOI: 10.1159/000441809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/18/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic hemodialysis (HD) in the 1960s encompassed a wide variety of prescriptions from twice weekly to five times per week HD. Over time, HD prescriptions in the West became standardized at three times per week, 2.5-4 h per session, with occasional additional treatments for volume overload. SUMMARY When clinical trials of dialysis dose failed to show significant benefit of extending time compared with the traditional dialysis prescription, interest in more frequent HD was renewed. Consequently, there has been growth in home HD therapies as well as alternative dialysis prescriptions. Data from recent randomized clinical trials have demonstrated the benefits and risks of these more frequent therapies, with surprising differences in outcomes between short daily HD and long nocturnal HD. More frequent therapies improve control of both hypertension and hyperphosphatemia, but at the expense of increased vascular access complications and, at least for nocturnal HD, a faster loss of residual renal function. KEY MESSAGES In the West, the standard HD prescription is three treatments per week with a minimal time of 3.0 h and dialysis is performed in an outpatient dialysis center. A minority of patients will have a fourth treatment per week for volume issues. Alternative HD prescriptions, although rare, are more available compared to the recent past. FACTS FROM EAST AND WEST (1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.
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Affiliation(s)
- Michael V. Rocco
- Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, N.C., USA
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15
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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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Nadeau-Fredette AC, Hawley CM, Pascoe EM, Chan CT, Clayton PA, Polkinghorne KR, Boudville N, Leblanc M, Johnson DW. An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry). Clin J Am Soc Nephrol 2015; 10:1397-407. [PMID: 26068181 PMCID: PMC4527016 DOI: 10.2215/cjn.00840115] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Home dialysis is often recognized as a first-choice therapy for patients initiating dialysis. However, studies comparing clinical outcomes between peritoneal dialysis and home hemodialysis have been very limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This Australia and New Zealand Dialysis and Transplantation Registry study assessed all Australian and New Zealand adult patients receiving home dialysis on day 90 after initiation of RRT between 2000 and 2012. The primary outcome was overall survival. The secondary outcomes were on-treatment survival, patient and technique survival, and death-censored technique survival. All results were adjusted with three prespecified models: multivariable Cox proportional hazards model (main model), propensity score quintile-stratified model, and propensity score-matched model. RESULTS The study included 10,710 patients on incident peritoneal dialysis and 706 patients on incident home hemodialysis. Treatment with home hemodialysis was associated with better patient survival than treatment with peritoneal dialysis (5-year survival: 85% versus 44%, respectively; log-rank P<0.001). Using multivariable Cox proportional hazards analysis, home hemodialysis was associated with superior patient survival (hazard ratio for overall death, 0.47; 95% confidence interval, 0.38 to 0.59) as well as better on-treatment survival (hazard ratio for on-treatment death, 0.34; 95% confidence interval, 0.26 to 0.45), composite patient and technique survival (hazard ratio for death or technique failure, 0.34; 95% confidence interval, 0.29 to 0.40), and death-censored technique survival (hazard ratio for technique failure, 0.34; 95% confidence interval, 0.28 to 0.41). Similar results were obtained with the propensity score models as well as sensitivity analyses using competing risks models and different definitions for technique failure and lag period after modality switch, during which events were attributed to the initial modality. CONCLUSIONS Home hemodialysis was associated with superior patient and technique survival compared with peritoneal dialysis.
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Affiliation(s)
- Annie-Claire Nadeau-Fredette
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Medicine, Université de Montreal, Montreal, Canada
| | - Carmel M Hawley
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - Elaine M Pascoe
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kevan R Polkinghorne
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Department of Nephrology, Monash Medical Centre, Monash Health, Clayton, Australia; Departments of Medicine, Epidemiology, and Preventative Medicine, Monash University, Melbourne, Australia; and
| | - Neil Boudville
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Martine Leblanc
- Department of Medicine, Université de Montreal, Montreal, Canada
| | - David W Johnson
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia;
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Wald R, Goldstein MB, Perl J, Kiaii M, Yuen D, Wald RM, Harel Z, Weinstein JJ, Jakubovic B, Leong-Poi H, Kirpalani A, Leipsic J, Dacouris N, Wolf M, Yan AT. The Association Between Conversion to In-centre Nocturnal Hemodialysis and Left Ventricular Mass Regression in Patients With End-Stage Renal Disease. Can J Cardiol 2015; 32:369-77. [PMID: 26386732 DOI: 10.1016/j.cjca.2015.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/26/2015] [Accepted: 07/05/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In-centre nocturnal hemodialysis (INHD, 7-8 hours/session, 3 times/week) is an increasingly utilized form of dialysis intensification, though data on the cardiovascular benefits of this modality are limited. METHODS In this prospective cohort study, we enrolled 67 prevalent conventional hemodialysis (CHD, 4 hours/session, 3 times/week) recipients at 2 medical centres in Canada, of whom 37 converted to INHD and 30 remained on CHD. The primary outcome was the change in left ventricular mass (LVM) after 1 year as assessed by cardiac magnetic resonance imaging. Secondary outcomes included changes in serum phosphate concentration, phosphate binder burden, haemoglobin, erythropoiesis stimulating agent usage, and blood pressure. RESULTS Conversion to INHD was associated with a 14.2 (95% confidence interval [CI] 1.2-27.2) g reduction in LVM as compared with continuation on CHD. This result was maintained after adjustment for baseline imbalances between the groups and in ancillary analyses. There was a trend toward a larger drop in systolic blood pressure (9.8 [95% CI, -1.4-20.9] mm Hg) among INHD recipients with a significant reduction in the number of prescribed antihypertensive agents (0.7 [95% CI, 0.3-1.1] agents). Serum phosphate declined by 0.40 (95% CI, 0.16-0.63) mmol/L among INHD recipients without any difference in calcium-based phosphate binder requirements, as compared with those who remained on CHD. CONCLUSIONS Compared with continuation of CHD, conversion to INHD was associated with significant LVM regression and reduction in serum phosphate concentration at 1 year.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
| | - Marc B Goldstein
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Perl
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren Yuen
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Rachel M Wald
- Divisions of Cardiology and Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Jordan J Weinstein
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Baruch Jakubovic
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Howard Leong-Poi
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Division of Cardiology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Anish Kirpalani
- Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jonathon Leipsic
- Department of Radiology and Division of Cardiology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Niki Dacouris
- Division of Nephrology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Myles Wolf
- Division of Nephrology and Center for Translational Metabolism and Health - Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew T Yan
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Division of Cardiology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Eloot S, Van Biesen W, Axelsen M, Glorieux G, Pedersen RS, Heaf JG. Protein-bound solute removal during extended multipass versus standard hemodialysis. BMC Nephrol 2015; 16:57. [PMID: 25896788 PMCID: PMC4404563 DOI: 10.1186/s12882-015-0056-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Multipass hemodialysis (MPHD) is a recently described dialysis modality, involving the use of small volumes of dialysate which are repetitively recycled. Dialysis regimes of 8 hours for six days a week using this device result in an increased removal of small water soluble solutes and middle molecules compared to standard hemodialysis (SHD). Since protein-bound solutes (PBS) exert important pathophysiological effects, we investigated whether MPHD results in improved removal of PBS as well. Methods A cross-over study (Clinical Trial NCT01267760) was performed in nine stable HD patients. At midweek a single dialysis session was performed with either 4 hours SHD using a dialysate flow of 500 mL/min or 8 hours MPHD with a dialysate volume of 50% of estimated body water volume. Blood and dialysate samples were taken every hour to determine concentrations of p-cresylglucuronide (PCG), hippuric acid (HA), indole acetic acid (IAA), indoxyl sulfate (IS), and p-cresylsulfate (PCS). Dialyser extraction ratio, reduction ratio, and solute removal were calculated for these solutes. Results Already at 60 min after dialysis start, the extraction ratio in the hemodialyser was a factor 1.4-4 lower with MPHD versus SHD, resulting in significantly smaller reduction ratios and lower solute removal within a single session. Even when extrapolating our findings to 3 times 4 h SHD and 6 times 8 h MPHD per week, the latter modality was at best similar in terms of total solute removal for most protein-bound solutes, and worse for the highly protein-bound solutes IS and PCS. When efficiency was calculated as solute removal/litre of dialysate used, MPHD was found superior to SHD. Conclusion When high water consumption is a concern, a treatment regimen of 6 times/week 8 h MPHD might be an alternative for 3 times/week 4 h SHD, but at the expense of a lower total solute removal of highly protein-bound solutes.
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Affiliation(s)
- Sunny Eloot
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Mette Axelsen
- Institute of Public Health, Aarhus University, Nordre Ringgade 1, 8000, Aarhus C, Denmark.
| | - Griet Glorieux
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | | | - James Goya Heaf
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Thomson BKA, Huang SHS, Lindsay RM. The choice of dialysate sodium is influenced by hemodialysis frequency and duration: what should it be and for what modality? Semin Dial 2014; 28:180-5. [PMID: 25482159 DOI: 10.1111/sdi.12330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cardiovascular disease is the leading cause of mortality in hemodialysis patients. A chronic state of volume and pressure overload contributes, and central to this is the net sodium balance over the course of a hemodialysis. Of recent interest is the contribution of the dialysate sodium concentration (Dial-Na+) to clinical outcomes. Abundant evidence confirms that in thrice-weekly conventional hemodialysis, higher Dial-Na+ associates with increased intradialytic weight gain, blood pressure, and cardiovascular morbidity and mortality. On the other hand, low Dial-Na+ associates with intradialytic hypotension in the same patient population. However, the effect of Dial-Na+ in short hours daily hemodialysis (SHD; often referred to as "quotidian" dialysis), or nocturnal dialysis (FHND) is less well studied. Increased frequency and duration of exposure to a diffusive sodium gradient modulate the way in which DPNa+ alters interdialytic weight gain, predialysis blood pressure, and intradialytic change in blood pressure. Furthermore, increased dialysis frequency appears to decrease the predialysis plasma sodium setpoint (SP), which is considered stable in conventional thrice-weekly patients. This review discusses criteria to determine optimal Dial-Na+ in conventional, SHD and FHND patients, and identifies areas for future research.
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Affiliation(s)
- Benjamin K A Thomson
- Division of Nephrology, Department of Medicine, London Health Sciences Centre and Western University, London, Ontario, Canada; Kidney Clinical Research Unit, London Health Sciences Centre and Western University, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada
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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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Watanabe Y, Ohno Y, Inoue T, Takane H, Okada H, Suzuki H. Home hemodialysis and conventional in-center hemodialysis in Japan: A comparison of health-related quality of life. Hemodial Int 2014; 18 Suppl 1:S32-8. [DOI: 10.1111/hdi.12221] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yusuke Watanabe
- Department of Nephrology; Saitama Medical University; Saitama Japan
| | - Yoichi Ohno
- Department of Nephrology; Saitama Medical University; Saitama Japan
| | - Tsutomu Inoue
- Department of Nephrology; Saitama Medical University; Saitama Japan
| | - Hiroshi Takane
- Department of Nephrology; Saitama Medical University; Saitama Japan
| | - Hirokazu Okada
- Department of Nephrology; Saitama Medical University; Saitama Japan
| | - Hiromichi Suzuki
- Department of Nephrology; Saitama Medical University; Saitama Japan
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Locatelli F, Altieri P, Andrulli S, Sau G, Bolasco P, Pedrini LA, Basile C, David S, Gazzanelli L, Tampieri G, Isola E, Marzolla O, Memoli B, Ganadu M, Reina E, Bertoli S, Ferrara R, Casu D, Logias F, Tarchini R, Mattana G, Passaghe M, Fundoni G, Villa G, Di Iorio BR, Pontoriero G, Zoccali C. Phosphate levels in patients treated with low-flux haemodialysis, pre-dilution haemofiltration and haemodiafiltration: post hoc analysis of a multicentre, randomized and controlled trial. Nephrol Dial Transplant 2014; 29:1239-1246. [DOI: 10.1093/ndt/gfu031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Eloot S, Ledebo I, Ward RA. Extracorporeal Removal of Uremic Toxins: Can We Still Do Better? Semin Nephrol 2014; 34:209-27. [DOI: 10.1016/j.semnephrol.2014.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Fluck RJ, Fouque D, Lockridge RS. Nephrologists' perspectives on dialysis treatment: results of an international survey. BMC Nephrol 2014; 15:16. [PMID: 24428875 PMCID: PMC3912927 DOI: 10.1186/1471-2369-15-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 01/03/2014] [Indexed: 02/02/2023] Open
Abstract
Background In-centre haemodialysis (ICHD) is the most common dialysis method used by patients worldwide. However, quality of life and clinical outcomes in patients treated via ICHD have not improved for some time. ‘High-dose’ haemodialysis (HD) regimens – which are longer and/or more frequent than conventional regimens and are particularly suitable to delivery in the home – may offer a route to improved outcomes and quality of life. This survey aimed to determine nephrologists’ views on the validity of alternatives to ICHD, particularly home HD and high-dose HD. Methods A total of 1,500 nephrologists from Europe, Canada and the United States were asked to respond to an online questionnaire that was designed following previous qualitative research. Certified nephrologists in practice for 2–35 years who managed >25 adult dialysis patients were eligible to take part. Results A total of 324 nephrologists completed the survey. ICHD was the most common type of dialysis used by respondents’ current patients (90%), followed by peritoneal dialysis (8%) and home HD (2%). The majority of respondents believed that: home HD provides better quality of life; increasing the frequency of dialysis beyond three times per week significantly improves clinical outcomes; and longer dialysis sessions performed nocturnally would result in significantly better clinical outcomes than traditional ICHD. Conclusions Survey results indicated that many nephrologists believe that home HD and high-dose HD are better for the patient. However, the majority of their patients were using ICHD. Education, training and support on alternative dialysis regimens are needed.
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Oh MS, Uribarri J. What can we learn from the saga of chitosan gums in hyperphosphatemia therapy? Clin J Am Soc Nephrol 2014; 9:967-70. [PMID: 24408115 DOI: 10.2215/cjn.09230913] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Control of high serum phosphorus, a marker of poor outcome, is still a poorly achieved goal in dialysis therapy. Therefore, the 2009 study (Savica et al., J Am Soc Nephrol 20: 639-644, 2009) showing a significant drop of serum phosphate (2.35 mg/dl) after only 2 weeks of chewing a chitosan-containing gum two times per day was received with great hopes by the renal community. Chitosan is a polymer of glucosamine, similar to sevelamer, which allegedly would bind phosphate present in high concentrations in the saliva of renal patients. Recent randomized studies, however, have been unable to duplicate these results. A systematic and detailed quantitative analysis of the available data was performed. It concluded that the amount of chitosan contained in the chewing gum (20 mg) is too little to account for the originally observed reduction in serum phosphate and be of any use as a phosphate binding agent in the management of hyperphosphatemia. It was postulated that the original marked drop in serum phosphate may have been caused by the Hawthorne effect, which is frequently observed in nonrandomized clinical trials. Two important lessons derived from this analysis are emphasized. The first lesson is the demonstration of the importance of randomized, placebo-controlled studies in clinical research. If randomization had been performed in the original study, the Hawthorne effect would have been detected. The second lesson is showing the importance of quantitative analysis, which in this case, would have avoided the time and effort expended in several randomized clinical trials that eventually concluded the ineffectiveness of the chitosan-containing chewing gums as a phosphate binder.
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Affiliation(s)
- Man S Oh
- Nephrology Division, Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, New York, †Nephrology Division, Department of Medicine, Mount Sinai School of Medicine, New York, New York
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Eloot S, Van Biesen W, Glorieux G, Neirynck N, Dhondt A, Vanholder R. Does the adequacy parameter Kt/V(urea) reflect uremic toxin concentrations in hemodialysis patients? PLoS One 2013; 8:e76838. [PMID: 24236005 PMCID: PMC3827207 DOI: 10.1371/journal.pone.0076838] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 08/31/2013] [Indexed: 11/18/2022] Open
Abstract
Hemodialysis aims at removing uremic toxins thus decreasing their concentrations. The present study investigated whether Kt/Vurea, used as marker of dialysis adequacy, is correlated with these concentrations. Predialysis blood samples were taken before a midweek session in 71 chronic HD patients. Samples were analyzed by colorimetry, HPLC, or ELISA for a broad range of uremic solutes. Solute concentrations were divided into four groups according to quartiles of Kt/Vurea, and also of different other parameters with potential impact, such as age, body weight (BW), Protein equivalent of Nitrogen Appearance (PNA), Residual Renal Function (RRF), and dialysis vintage. Dichotomic concentration comparisons were performed for gender and Diabetes Mellitus (DM). Analysis of Variance in quartiles of Kt/Vurea did not show significant differences for any of the solute concentrations. For PNA, however, concentrations showed significant differences for urea (P<0.001), uric acid (UA), p-cresylsulfate (PCS), and free PCS (all P<0.01), and for creatinine (Crea) and hippuric acid (HA) (both P<0.05). For RRF, concentrations varied for β2-microglobulin (P<0.001), HA, free HA, free indoxyl sulfate, and free indole acetic acid (all P<0.01), and for p-cresylglucuronide (PCG), 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid (CMPF), free PCS, and free PCG (all P<0.05). Gender and body weight only showed differences for Crea and UA, while age, vintage, and diabetes mellitus only showed differences for one solute concentration (UA, UA, and free PCS, respectively). Multifactor analyses indicated a predominant association of concentration with protein intake and residual renal function. In conclusion, predialysis concentrations of uremic toxins seem to be dependent on protein equivalent of nitrogen appearance and residual renal function, and not on dialysis adequacy as assessed by Kt/Vurea. Efforts to control intestinal load of uremic toxin precursors by dietary or other interventions, and preserving RRF seem important approaches to decrease uremic solute concentration and by extension their toxicity.
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Affiliation(s)
- Sunny Eloot
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
- * E-mail:
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Nathalie Neirynck
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Annemieke Dhondt
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
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Tennankore K, Nadeau-Fredette AC, Chan CT. Intensified home hemodialysis: clinical benefits, risks and target populations. Nephrol Dial Transplant 2013; 29:1342-9. [DOI: 10.1093/ndt/gft383] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Badve SV, Beller EM, Cass A, Francis DP, Hawley C, Macdougall IC, Perkovic V, Johnson DW. Interventions for erythropoietin-resistant anaemia in dialysis patients. Cochrane Database Syst Rev 2013:CD006861. [PMID: 23979995 DOI: 10.1002/14651858.cd006861.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND People living with end-stage kidney disease (ESKD) often develop anaemia. Erythropoiesis-simulating agents (ESAs) are often given to people living with ESKD to maintain haemoglobin at a level to minimise need for transfusion. However, about 5% to 10% of patients with ESKD exhibit resistance to ESAs, and observational studies have shown that patients requiring high doses of ESA are at increased risk of mortality. OBJECTIVES This review aimed to study the effects of interventions for the treatment of ESA-resistant anaemia in people with ESKD. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for randomised controlled trials (RCT) that involved participants with ESKD on dialysis or who were pre-dialysis patients with chronic kidney disease (stage 5). Date of last search: April 2013. SELECTION CRITERIA ESA resistance was defined as failure to achieve or maintain haemoglobin/haematocrit levels within the desired target range despite appropriate ESA doses (erythropoietin ≥ 450 U/kg/wk intravenously or ≥ 300 U/kg/wk subcutaneously; darbepoetin ≥ 1.5 µg/kg/wk) in people who were not nutritionally deficient, or who had haematological or bleeding disorders. Extended inclusion criteria for ESA hyporesponsive state were: erythropoietin dose ≥ 300 U/kg/wk and ≥ 150 U/kg/wk for intravenous administration; or ≥ 200 U/kg/wk and ≥ 100 U/kg/wk for subcutaneous administration; or darbepoetin dose ≥ 1.0 µg/kg/wk). DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS Titles and abstracts of 521 records were screened, of which we reviewed 99 from the full text. Only two studies matched our inclusion criteria. One study compared intravenous vitamin C versus no study medication for six months in 42 ESKD patients on haemodialysis who required intravenous erythropoietin (dose ≥ 450 U/kg/wk). The other included study compared high-flux dialyser versus low-flux dialyser for six months in 48 haemodialysis patients who required subcutaneous erythropoietin (dose ≥ 200 U/kg/wk). Because interventions differed, data could not be combined for quantitative meta-analysis. AUTHORS' CONCLUSIONS There was inadequate evidence identified to inform recommendation of any intervention to ameliorate ESA hyporesponsiveness. Adequately powered RCTs are required to establish the safety and efficacy of interventions to improve responsiveness to ESA therapy.
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Affiliation(s)
- Sunil V Badve
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia, 4102
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Wester M, Simonis F, Gerritsen KG, Boer WH, Wodzig WK, Kooman JP, Joles JA. A regenerable potassium and phosphate sorbent system to enhance dialysis efficacy and device portability: an in vitro study. Nephrol Dial Transplant 2013; 28:2364-71. [DOI: 10.1093/ndt/gft205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kalantar-Zadeh K. Patient education for phosphorus management in chronic kidney disease. Patient Prefer Adherence 2013; 7:379-90. [PMID: 23667310 PMCID: PMC3650565 DOI: 10.2147/ppa.s43486] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This review explores the challenges and solutions in educating patients with chronic kidney disease (CKD) to lower serum phosphorus while avoiding protein insufficiency and hypercalcemia. METHODS A literature search including terms "hyperphosphatemia," "patient education," "food fatigue," "hypercalcemia," and "phosphorus-protein ratio" was undertaken using PubMed. RESULTS Hyperphosphatemia is a strong predictor of mortality in advanced CKD and is remediated via diet, phosphorus binders, and dialysis. Dietary counseling should encourage the consumption of foods with the least amount of inorganic or absorbable phosphorus, low phosphorus-to-protein ratios, and adequate protein content, and discourage excessive calcium intake in high-risk patients. Emerging educational initiatives include food labeling using a "traffic light" scheme, motivational interviewing techniques, and the Phosphate Education Program - whereby patients no longer have to memorize the phosphorus content of each individual food component, but only a "phosphorus unit" value for a limited number of food groups. Phosphorus binders are associated with a clear survival advantage in CKD patients, overcome the limitations associated with dietary phosphorus restriction, and permit a more flexible approach to achieving normalization of phosphorus levels. CONCLUSION Patient education on phosphorus and calcium management can improve concordance and adherence and empower patients to collaborate actively for optimal control of mineral metabolism.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine’s School of Medicine, Irvine, CA, USA
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Rocco MV. Does More Frequent Hemodialysis Provide Dietary Freedom? J Ren Nutr 2013; 23:259-62. [DOI: 10.1053/j.jrn.2013.01.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 01/20/2013] [Indexed: 11/11/2022] Open
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Novel techniques and innovation in blood purification: a clinical update from Kidney Disease: Improving Global Outcomes. Kidney Int 2013; 83:359-71. [DOI: 10.1038/ki.2012.450] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Patients receiving conventional hemodialysis have high hospitalisation rates, poor quality of life and survival compared to the general population. Many centres around the world are providing longer hours of hemodialysis - short daily hemodialysis and nocturnal hemodialysis - with a view to improving patient survival and quality of life. Studies have shown that nocturnal haemodiaysis is more effective than conventional hemodialysis in clearing most small, middle and larger molecule toxins and suggest nocturnal dialysis enhances patient survival and quality of life. Concerns include patient acceptance, vascular access related complications and increased cost. The purpose of this review is to examine the advantages and drawbacks of nocturnal dialysis, with a focus on applicability to India where the renal physician has to face cultural and economic barriers, erratic power supply and poor water quality.
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Affiliation(s)
- D Ranganathan
- Department of Renal Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Vanholder R, Eloot S, Van Biesen W, Lameire N. Less water for haemodialysis: is multiple pass the future pace to go? Nephrol Dial Transplant 2013; 28:1067-70. [PMID: 23291373 DOI: 10.1093/ndt/gfs546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kong X, Zhang L, Zhang L, Chen N, Gu Y, Yu X, Liu W, Chen J, Peng L, Yuan W, Wu H, Chen W, Fan M, He L, Ding F, Chen X, Xiong Z, Zhang J, Jia Q, Shi W, Xing C, Tang X, Hou F, Shu G, Mei C, Wang L, Xu D, Ni Z, Zuo L, Wang M, Wang H. Mineral and bone disorder in Chinese dialysis patients: a multicenter study. BMC Nephrol 2012; 13:116. [PMID: 22994525 PMCID: PMC3507668 DOI: 10.1186/1471-2369-13-116] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 09/14/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mineral and bone disorder (MBD) in patients with chronic kidney disease is associated with increased morbidity and mortality. Studies regarding the status of MBD treatment in developing countries, especially in Chinese dialysis patients are extremely limited. METHODS A cross-sectional study of 1711 haemodialysis (HD) patients and 363 peritoneal dialysis (PD) patients were enrolled. Parameters related to MBD, including serum phosphorus (P), calcium (Ca), intact parathyroid hormone (iPTH) were analyzed. The achievement of MBD targets was compared with the results from the Dialysis Outcomes and Practice Study (DOPPS) 3 and DOPPS 4. Factors associated with hyperphosphatemia were examined. RESULTS Total 2074 dialysis patients from 28 hospitals were involved in this study. Only 38.5%, 39.6% and 26.6% of them met the Kidney Disease Outcomes Quality Initiative (K/DOQI) defined targets for serum P, Ca and iPTH levels. Serum P and Ca levels were statistically higher (P < 0.05) in the HD patients compared with those of PD patients, which was (6.3 ± 2.1) mg/dL vs (5.7 ± 2.0) mg/dL and (9.3 ± 1.1) mg/dL vs (9.2 ± 1.1) mg/dL, respectively. Serum iPTH level were statistically higher in the PD patients compared with those of HD patients (P = 0.03). The percentage of patients reached the K/DOQI targets for P (37.6% vs 49.8% vs 54.5%, P < 0.01), Ca (38.6% vs 50.4% vs 56.0%, P < 0.01) and iPTH (26.5% vs 31.4% vs 32.1%, P < 0.01) were lower among HD patients, compared with the data from DOPPS 3 and DOPPS 4. The percentage of patients with serum phosphorus level above 5.5 mg/dL was 57.4% in HD patients and 47.4% in PD patients. Age, dialysis patterns and region of residency were independently associated with hyperphosphatemia. CONCLUSIONS Status of MBD is sub-optimal among Chinese patients receiving dialysis. The issue of hyperphosphatemia is prominent and needs further attention.
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Affiliation(s)
- Xianglei Kong
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yong Gu
- Renal Division, Xinhua Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xueqing Yu
- Department of Nephrology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jianghua Chen
- Kidney Diseases Center, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liren Peng
- Department of Nephrology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Weijie Yuan
- Department of Nephrology, Shanghai First People s Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Hua Wu
- Department of Nephrology, Beijing Hospital, Beijing, China
| | - Wei Chen
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Minhua Fan
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Liqun He
- Department of Nephrology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Feng Ding
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiangmei Chen
- Department of Nephrology, The General Hospital of the People's Liberation Army, Beijing, China
| | - Zuying Xiong
- Renal Division, Hospital Peking of Shenzhen, Shenzhen, China
| | - Jinyuan Zhang
- Department of Nephrology, The 455th Hospital of PLA, Shanghai, China
| | - Qiang Jia
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Shi
- Department of Nephrology, Guangdong General Hospital, Guangzhou, China
| | - Changying Xing
- Renal Division, Jiangsu Provincial Hospital, Nanjing, China
| | - Xiaoling Tang
- Department of internal medicine, Shantou Central Hospital, Shantou, China
| | - Fanfan Hou
- Department of Nephrology, Nanfang Hospital, The Southern Medical University, Guangzhou, China
| | - Guiyang Shu
- Department of Nephrology, Fujian Provincial Hospital, Fuzhou, China
| | - Changlin Mei
- Department of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Li Wang
- Department of Nephrology, Sichuan Provincial People’ s Hospital, Chengdu, China
| | - Dongmei Xu
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Zhaohui Ni
- Renal Division, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Zuo
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Mei Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
- Institute of Nephrology and Division of Nephrology, and Key Laboratory of Ministry of Health, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Haiyan Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
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Tennankore KK, Chan CT, Curran SP. Intensive home haemodialysis: benefits and barriers. Nat Rev Nephrol 2012; 8:515-22. [DOI: 10.1038/nrneph.2012.145] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Daugirdas JT, Chertow GM, Larive B, Pierratos A, Greene T, Ayus JC, Kendrick CA, James SH, Miller BW, Schulman G, Salusky IB, Kliger AS. Effects of frequent hemodialysis on measures of CKD mineral and bone disorder. J Am Soc Nephrol 2012; 23:727-38. [PMID: 22362907 PMCID: PMC3312501 DOI: 10.1681/asn.2011070688] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 12/03/2011] [Indexed: 11/03/2022] Open
Abstract
More frequent hemodialysis sessions and longer session lengths may offer improved phosphorus control. We analyzed data from the Frequent Hemodialysis Network Daily and Nocturnal Trials to examine the effects of treatment assignment on predialysis serum phosphorus and on prescribed dose of phosphorus binder, expressed relative to calcium carbonate on a weight basis. In the Daily Trial, with prescribed session lengths of 1.5-2.75 hours six times per week, assignment to frequent hemodialysis associated with both a 0.46 mg/dl decrease (95% confidence interval [95% CI], 0.13-0.78 mg/dl) in mean serum phosphorus and a 1.35 g/d reduction (95% CI, 0.20-2.50 g/d) in equivalent phosphorus binder dose at month 12 compared with assignment to conventional hemodialysis. In the Nocturnal Trial, with prescribed session lengths of 6-8 hours six times per week, assignment to frequent hemodialysis associated with a 1.24 mg/dl decrease (95% CI, 0.68-1.79 mg/dl) in mean serum phosphorus compared with assignment to conventional hemodialysis. Among patients assigned to the group receiving six sessions per week, 73% did not require phosphorus binders at month 12 compared with only 8% of patients assigned to sessions three times per week (P<0.001). At month 12, 42% of patients on nocturnal hemodialysis required the addition of phosphorus into the dialysate to prevent hypophosphatemia. Frequent hemodialysis did not have major effects on calcium or parathyroid hormone concentrations in either trial. In conclusion, frequent hemodialysis facilitates control of hyperphosphatemia and extended session lengths could allow more liberal diets and freedom from phosphorus binders.
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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. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Health care policy is encouraging expansion of home haemodialysis, aiming to improve patient outcomes and reduce cost. However, most patient outcome data derive from retrospective observational studies, with all their inherent weaknesses. Conventional thrice weekly home haemodialysis delivers a 22-51% reduction in mortality, but why should that be? Frequent and/or nocturnal haemodialysis reduces mortality by 36-66%, with comparable outcomes to deceased donor kidney transplantation. Approaches which might improve the quality of future observational studies are discussed. Patient-relevant outcomes other than mortality are also discussed.
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Affiliation(s)
- Mark S MacGregor
- John Stevenson Lynch Renal Unit, NHS Ayrshire & Arran, Crosshouse Hospital, Kilmarnock, Scotland
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Moorthi RN, Moe SM. CKD-mineral and bone disorder: core curriculum 2011. Am J Kidney Dis 2011; 58:1022-36. [PMID: 22018457 PMCID: PMC3983665 DOI: 10.1053/j.ajkd.2011.08.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 08/16/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Ranjani N Moorthi
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, IN 46202, USA.
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Marshall MR, Hawley CM, Kerr PG, Polkinghorne KR, Marshall RJ, Agar JW, McDonald SP. Home Hemodialysis and Mortality Risk in Australian and New Zealand Populations. Am J Kidney Dis 2011; 58:782-93. [DOI: 10.1053/j.ajkd.2011.04.027] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 04/22/2011] [Indexed: 11/11/2022]
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Therapeutic interventions for chronic kidney disease-mineral and bone disorders: focus on mortality. Curr Opin Nephrol Hypertens 2011; 20:376-81. [DOI: 10.1097/mnh.0b013e328346f93f] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Nocturnal hemodialysis: effects on solute clearance, quality of life, and patient survival. Curr Opin Nephrol Hypertens 2011; 20:182-8. [PMID: 21252663 DOI: 10.1097/mnh.0b013e3283437046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Conventional hemodialysis is often an incomplete treatment for uremia. People receiving hemodialysis often report a poor quality of life and suffer from an accelerated mortality rate. Nocturnal hemodialysis provides long treatments at night in the home or dialysis center. This review will examine how long nocturnal treatments have impact on the clearance of small and larger retention products, and how these treatments influence quality of life and survival. RECENT FINDINGS Nocturnal hemodialysis is more effective at clearing most small and middle molecule retention products, and has been associated with improvements in quality of life, especially in those domains related to the effects of kidney disease. Survival on nocturnal hemodialysis is higher than expected, and studies suggest that patients receiving nocturnal hemodialysis have a mortality rate that is about one third of what is seen in similar patients receiving conventional hemodialysis. SUMMARY Although impressive, it is difficult to be sure how much of the results of these studies is due to the duration and timing of dialysis and how much relates to patient level factors and residual confounding, and further research in this area is required.
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Lau WL, Festing MH, Giachelli CM. Phosphate and vascular calcification: Emerging role of the sodium-dependent phosphate co-transporter PiT-1. Thromb Haemost 2010; 104:464-70. [PMID: 20664908 DOI: 10.1160/th09-12-0814] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 07/01/2010] [Indexed: 12/16/2022]
Abstract
Elevated serum phosphate is a risk factor for vascular calcification and cardiovascular events in kidney disease as well as in the general population. Elevated phosphate levels drive vascular calcification, in part, by regulating vascular smooth muscle cell (VSMC) gene expression, function, and fate. The type III sodium-dependent phosphate co-transporter, PiT-1, is necessary for phosphate-induced VSMC osteochondrogenic phenotype change and calcification, and has recently been shown to have unexpected functions in cell proliferation and embryonic development.
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Affiliation(s)
- Wei Ling Lau
- Nephrology, University of Washington, Seattle, Washington, USA
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