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Platnich JM, Pauly RP. Patient Training and Patient Safety in Home Hemodialysis. Clin J Am Soc Nephrol 2024; 19:1045-1050. [PMID: 38190130 PMCID: PMC11321743 DOI: 10.2215/cjn.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.
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Affiliation(s)
- Jaye M Platnich
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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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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Ok E, Demirci C, Asci G, Yuksel K, Kircelli F, Koc SK, Erten S, Mahsereci E, Odabas AR, Stuard S, Maddux FW, Raimann JG, Kotanko P, Kerr PG, Chan CT. Patient Survival With Extended Home Hemodialysis Compared to In-Center Conventional Hemodialysis. Kidney Int Rep 2023; 8:2603-2615. [PMID: 38106580 PMCID: PMC10719649 DOI: 10.1016/j.ekir.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up. Methods We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters. Results The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR] = 0.60; 95% confidence interval [CI] 0.45 to 0.80; P < 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement. Conclusion These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.
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Roblero MFS, Rubio MAB, González-Moya M, Varela JC, Alba AP, Gumpert JV, Cigarrán S, Vidau P, Marcos SG, Luquin PA, Piera EC, Mariño AG, Espigares MJ, Molina MD, Molina P. Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. Nefrologia 2022; 42:460-470. [PMID: 36400687 DOI: 10.1016/j.nefroe.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 07/12/2021] [Indexed: 06/16/2023] Open
Abstract
Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Pedro Vidau
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | | | | | - Mariola D Molina
- Departamento de Matemáticas, Universidad de Alicante, San Vicente del Raspeig, Alicante, Spain
| | - Pablo Molina
- Hospital Universitari Dr Peset, FISABIO, Departamento de Medicina, Universitat de València, Valencia, Spain
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5
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Slon Roblero MF, Bajo Rubio MA, González-Moya M, Calviño Varela J, Pérez Alba A, Villaro Gumpert J, Cigarrán S, Vidau P, García Marcos S, Abáigar Luquin P, Coll Piera E, Gascón Mariño A, Espigares MJ, Molina MD, Molina P. Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. Nefrologia 2021; 42:S0211-6995(21)00144-2. [PMID: 34393002 DOI: 10.1016/j.nefro.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 11/25/2022] Open
Abstract
Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Pedro Vidau
- Hospital Universitario Central de Asturias, Oviedo, España
| | | | | | | | | | | | - Mariola D Molina
- Departamento de Matemáticas, Universidad de Alicante, San Vicente del Raspeig, Alicante, España
| | - Pablo Molina
- Hospital Universitari Dr Peset, FISABIO, Departamento de Medicina, Universitat de València, Valencia, España
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Tennankore KK, Nadeau-Fredette AC, Vinson AJ. Survival comparisons in home hemodialysis: Understanding the present and looking to the future. Nephrol Ther 2021; 17S:S64-S70. [PMID: 33910701 DOI: 10.1016/j.nephro.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/13/2020] [Indexed: 10/21/2022]
Abstract
A number of studies have compared relative survival for home hemodialysis patients (including longer hours/more frequent schedules) and other forms of renal replacement therapy. While informative, many of these studies have been limited by issues pertaining to their observational design including selection bias and residual confounding. Furthermore the few randomized controlled trials that have been conducted have been underpowered to detect a survival difference. Finally, in the face of a growing recognition of the value of patient-important outcomes beyond survival, the focus of comparisons between dialysis modalities may be changing. In this review, we will discuss the determinants of survival for patients receiving home hemodialysis and address the various studies that have compared relative survival for differing home hemodialysis schedules to each of in-center hemodialysis, peritoneal dialysis and transplantation. We will conclude this review by discussing whether there is an ongoing role for survival analyses in home hemodialysis.
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Affiliation(s)
- Karthik K Tennankore
- Dalhousie University/Nova Scotia Health Authority, 5082 Dickson Building, 5820, University Avenue, NS B3H 1V8 Halifax, Canada.
| | | | - Amanda J Vinson
- Dalhousie University/Nova Scotia Health Authority, 5082 Dickson Building, 5820, University Avenue, NS B3H 1V8 Halifax, Canada
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Abstract
Rationale & Objective Community house hemodialysis is a submodality of home hemodialysis that enables patients to perform hemodialysis independent of nursing or medical supervision in a shared house. This study describes the perspectives and experiences of patients using community house hemodialysis in New Zealand to explore ways this dialysis modality may support the wider delivery of independent hemodialysis care. Study Design Qualitative semi-structured in-depth interview study. Setting & Participants 25 patients who had experienced community house hemodialysis. Participants were asked about why they chose community house hemodialysis and their experiences and perspectives of this. Analytical Approach Thematic analysis using an inductive approach. Results 25 patients were interviewed (14 men and 11 women, aged 31-65 years). Most were of Māori or Pacific ethnicity and in part- or full-time employment. More than two-thirds dialyzed for 20 hours a week or more. We identified 4 themes that described patients’ experiences and perspectives of choosing and using community house hemodialysis: reducing burden on family (when home is not an option, minimizing family exposure to dialysis, maintaining privacy and self-identity, reducing the costs of home hemodialysis, and gaining a reprieve from home), offering flexibility and freedom (having a normal life, maintaining employment, and facilitating travel), control of my health (building independence and self-efficacy, a place of wellness, avoiding institutionalization, and creating a culture of extended-hour dialysis), and community support (building social inclusion and supporting peers). Limitations Non-Māori and non-Pacific patient experiences of community house hemodialysis could not be explored. Conclusions Community house hemodialysis is a dialysis modality that overcomes many of the socioeconomic barriers to home hemodialysis, is socially and culturally acceptable to Māori and Pacific people, and supports extended-hour hemodialysis and thereby promotes more equitable access to best practice services. It is therefore a significant addition to independent hemodialysis options available for patients.
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Pladys A, Bayat S, Couchoud C, Vigneau C, McDonald S. Daily hemodialysis practices in Australia/New Zealand and in France: a comparative cohort study. BMC Nephrol 2019; 20:156. [PMID: 31064344 PMCID: PMC6505110 DOI: 10.1186/s12882-019-1330-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 04/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background As patients on daily hemodialysis (DHD) have heterogeneous profiles, DHD benefit in terms of survival is still debated. The aim of this study was to compare DHD practices in France and in Australia and New Zealand. Methods This study was based on data from the French Renal Epidemiology and Information Network (REIN) and the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). All incident patients from both registries who underwent DHD (i.e., 5–6 sessions/week, including short daily hemodialysis and long nocturnal hemodialysis) at least once during their trajectories were included, and their characteristics and care trajectories were compared. For survival analyses, one French patient was matched to one Australian or New Zealand patient, based on age, sex and year of dialysis start. Survival was assessed using the Cox proportional hazards model, and access to renal transplantation was evaluated using the Fine & Gray model to take into account death as competing risk. Results Between 2003 and 2012, 523 patients from the AZNDATA and 753 from the REIN registry started DHD. ANZDATA patients were younger (54.8 vs 64.0 years, p < 0.001) and had comorbidities more frequently than French patients. In both registries, one third of patients were on early DHD (i.e., DHD started less than one year after dialysis initiation). Long nocturnal hemodialysis was more frequent in the ANZDATA than in the REIN cohort (20.8 and 3%, respectively). Comparison of the matched subgroups showed comparable survival rates between French and Australian/New Zealand patients (HRadjusted = 1.08; 95%CI: 0.78–1.50). Access to renal transplantation also was similar between matched groups (SHRadjusted = 1.30, 95%CI: 0.86–1.97). Conclusions Our study shows that, despite differences in terms of patients’ characteristics and DHD regimens, the mortality risk and access to renal transplantation are similar in France and Australia and New Zealand. Electronic supplementary material The online version of this article (10.1186/s12882-019-1330-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adélaïde Pladys
- EHESP Rennes, Sorbonne Paris Cité, EA 7449 Reperes, Rennes, France.
| | - Sahar Bayat
- EHESP Rennes, Sorbonne Paris Cité, EA 7449 Reperes, Rennes, France
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN), Biomedecine Agency, Saint Denis La Plaine, France
| | - Cécile Vigneau
- University of Rennes 1, INSERM U1085-IRSET, Rennes, France.,CHU Pontchaillou, Department of Nephrology, Rennes, France
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.,University of Adelaide, Adelaide, Australia
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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10
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Haroon S, Davenport A. Haemodialysis at home: review of current dialysis machines. Expert Rev Med Devices 2018; 15:337-347. [DOI: 10.1080/17434440.2018.1465817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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11
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Kraus MA, Kansal S, Copland M, Komenda P, Weinhandl ED, Bakris GL, Chan CT, Fluck RJ, Burkart JM. Intensive Hemodialysis and Potential Risks With Increasing Treatment. Am J Kidney Dis 2017; 68:S51-S58. [PMID: 27772644 DOI: 10.1053/j.ajkd.2016.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 12/27/2022]
Abstract
Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.
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Affiliation(s)
| | - Sheru Kansal
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH
| | - Michael Copland
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Paul Komenda
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital Renal Program, Winnipeg, Canada
| | - Eric D Weinhandl
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN.
| | - George L Bakris
- American Society of Hypertension Comprehensive Hypertension Center, Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Christopher T Chan
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
| | - Richard J Fluck
- Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - John M Burkart
- Wake Forest University Medical Center, Winston-Salem, NC
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12
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Miller AJ, Perl J, Tennankore KK. Survival comparisons of intensive vs. conventional hemodialysis: Pitfalls and lessons. Hemodial Int 2017; 22:9-22. [DOI: 10.1111/hdi.12559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Amanda J. Miller
- Department of Medicine, Division of Nephrology; Nova Scotia Health Authority; Halifax Nova Scotia Canada
| | - Jeff Perl
- Department of Medicine, Division of Nephrology; University of Toronto; Toronto Ontario Canada
| | - Karthik K. Tennankore
- Department of Medicine, Division of Nephrology; Nova Scotia Health Authority; Halifax Nova Scotia Canada
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13
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Piccoli GB, Moio MR, Fois A, Sofronie A, Gendrot L, Cabiddu G, D'Alessandro C, Cupisti A. The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach. Nutrients 2017; 9:E372. [PMID: 28394304 PMCID: PMC5409711 DOI: 10.3390/nu9040372] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/25/2022] Open
Abstract
The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Maria Rita Moio
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Antioco Fois
- Nefrologia, Ospedale Brotzu, 09100 Cagliari, Italy.
| | - Andreea Sofronie
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
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Pladys A, Vigneau C, Hourmant M, Duneau G, Couchoud C, Bayat S. Association between daily haemodialysis, access to renal transplantation and patients' survival in France. Nephrology (Carlton) 2016; 23:269-278. [PMID: 27905676 DOI: 10.1111/nep.12974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/24/2016] [Accepted: 11/24/2016] [Indexed: 11/28/2022]
Abstract
AIM Daily haemodialysis improves patients' quality of life and blood purification, but its effect on survival remains controversial. The aim of this study was to analyze the association between daily haemodialysis and renal transplantation and survival in France. METHODS This was an observational cohort study based on the French REIN registry. All incident patients ≥18 years old who started daily haemodialysis in France between 2003 and 2012 were included. Using a propensity score, 575 patients on daily haemodialysis were matched with 1696 patients receiving thrice-weekly haemodialysis. Survival analysis was performed using the Cox model. Access to the renal transplant waiting list and renal transplantation were analyzed using the Fine and Gray model. RESULTS Daily haemodialysis was not independently associated with reduced access to transplant waiting list, whereas, major comorbidities remained associated with restricted waitlisting after multivariate analysis adjusted for confounding factors. After being waitlisted, the cumulative incidence of renal transplantation was lower for the daily haemodialysis than for the thrice-weekly haemodialysis group (SHR = 0.72, 95%CI: 0.56-0.91). The risk of death was significantly higher in the daily haemodialysis group (HRadjusted = 1.58, 95%CI: 1.4-1.8). Major comorbidities were associated with higher risk of death and lower likelihood of receiving a renal transplant during the follow-up period. CONCLUSION Our study showed that in France, the likelihood of undergoing renal transplantation after being waitlisted was lower for patients on daily haemodialysis than those on thrice-weekly haemodialysis. Moreover, daily haemodialysis was associated with higher risk of death, even after taking into account age and all major comorbidities.
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Affiliation(s)
- Adélaïde Pladys
- High French School of Public Health (EHESP: Ecole des Hautes Etude de Sante Publique), Rennes, France.,University of Rennes 1, UMR CNRS 6290, Rennes, France
| | - Cécile Vigneau
- University of Rennes 1, UMR CNRS 6290, Rennes, France.,Service of Nephrology, Pontchaillou hospital, Rennes, France
| | | | | | - Cécile Couchoud
- REIN (Renal Epidemiology and Information Network) registry, Biomedecine Agency, Saint Denis La Plaine, France
| | - Sahar Bayat
- High French School of Public Health (EHESP: Ecole des Hautes Etude de Sante Publique), Rennes, France
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15
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Pladys A, Bayat S, Kolko A, Béchade C, Couchoud C, Vigneau C. French patients on daily hemodialysis: clinical characteristics and treatment trajectories. BMC Nephrol 2016; 17:107. [PMID: 27473376 PMCID: PMC4966797 DOI: 10.1186/s12882-016-0306-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 06/14/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Increasing the weekly frequency of hemodialysis sessions has positive effects, on the control of several biological data of patients. However, knowledge about Daily HemoDialysis (DHD) practices is limited in France. The aim of the present study was to describe the characteristics and treatment trajectories of all French patients undergoing DHD. METHODS All patients older than 18 years who started DHD between 2003 and 2012 in France were included and followed until December 31, 2013. The patients' demographic and clinical characteristics and treatment modalities were extracted from the French Renal Epidemiological and Information Network (REIN) registry. RESULTS During the inclusion period, 753 patients started DHD in France. Based on their median age (64 years), patients were classified in two groups: "old" group (≥64 years) and "young" group (<64 years). Patients in the old group had more comorbidities than in the young group: 48 % had diabetes (vs 29 % in the young group), 17 % an active malignancy (vs 10 %) and 80 % ≥1 cardiovascular disease (vs 41 %). Concerning patients' treatment trajectories, 496 (66 %) patients started with another dialysis before switching to DHD and 257 (34 %) directly with DHD. At the end of the follow-up, 69 % of patients in the old group were dead (27.4 % in the young group) and kidney transplantation was more frequent in the young group (30.4 % vs 0.5 %). CONCLUSION In France, DHD is proposed not only to young in rather good clinical conditions and waiting for kidney transplantation, but also to old and frail patients with higher mortality.
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Affiliation(s)
- Adélaïde Pladys
- EHESP Rennes, Sorbonne Paris Cité, Rennes, France
- Université Rennes 1, UMR CNRS 6290, Rennes, France
| | - Sahar Bayat
- EHESP Rennes, Sorbonne Paris Cité, Rennes, France
- EHESP Rennes, Sorbonne Paris Cité, EA MOS, Rennes, France
| | | | - Clémence Béchade
- CHU Caen, Service de néphrologie, Caen, France
- Université de Caen Normandie, 1086 INSERM, Caen, France
| | - Cécile Couchoud
- Registre REIN, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Cécile Vigneau
- Université Rennes 1, UMR CNRS 6290, Rennes, France
- CHU Pontchaillou, Service de néphrologie, Rennes, France
| | - on behalf of the REIN registry
- EHESP Rennes, Sorbonne Paris Cité, Rennes, France
- Université Rennes 1, UMR CNRS 6290, Rennes, France
- EHESP Rennes, Sorbonne Paris Cité, EA MOS, Rennes, France
- Association AURA, Paris, France
- CHU Caen, Service de néphrologie, Caen, France
- Université de Caen Normandie, 1086 INSERM, Caen, France
- Registre REIN, Agence de la biomédecine, Saint Denis La Plaine, France
- CHU Pontchaillou, Service de néphrologie, Rennes, France
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16
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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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Wilcox SB, Carver M, Yau M, Sneeringer P, Prichard S, Alvarez L, Chertow GM. Results of human factors testing in a novel Hemodialysis system designed for ease of patient use. Hemodial Int 2016; 20:643-649. [DOI: 10.1111/hdi.12430] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - May Yau
- Outset Medical, Inc; San Jose California 95112 USA
| | | | | | - Luis Alvarez
- Division of Nephrology; Department of Medicine; Palo Alto Medical Foundation; Palo Alto California USA
| | - Glenn M. Chertow
- Division of Nephrology; Department of Medicine; Stanford University School of Medicine; Stanford California USA
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18
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Vega A, Sequí MJ, Abad S, Yuste C, Santos A, Macías N, López-Gómez JM. Daily Home Hemodialysis Is an Available Option for Renal Replacement Therapy in Spain. Ther Apher Dial 2016; 20:408-12. [PMID: 26991430 DOI: 10.1111/1744-9987.12400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/12/2015] [Accepted: 12/10/2015] [Indexed: 11/29/2022]
Abstract
The objective of the present study was to analyze the characteristics and survival of patients from our hospital who started home hemodialysis. We analyzed all patients receiving home hemodialysis from 1969 to 2015 (51 patients; age 45 ± 23 years; men 77%). We collected characteristics, hospital admission, and mortality. After a median follow-up of 43 (22-76) months, we found 0-1 hospital admissions per year. Sixty-nine percent received a kidney transplant, and the global mortality was 10%. Survival at 5 years was 96%. Mean equivalent renal urea clearance was 15.6 ± 4.2 mL/min, the β-2 microglobulin reduction rate was 67 ± 18%, the number of antihypertension drugs was 0.7 ± 0.3, and the erythropoietin resistance index was 3.7 ± 2.1 IU/kg/week/g/dL. Daily home hemodialysis is a viable option for renal replacement therapy and should be offered alongside other therapies.
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Affiliation(s)
- Almudena Vega
- Nephrology Unit, Hospital Gregorio Marañón, Madrid, Spain
| | | | - Soraya Abad
- Nephrology Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - Claudia Yuste
- Nephrology Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - Alba Santos
- Nephrology Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Nephrology Unit, Hospital Gregorio Marañón, Madrid, Spain
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Yau M, Carver M, Alvarez L, Block GA, Chertow GM. Understanding barriers to home-based and self-care in-center hemodialysis. Hemodial Int 2015; 20:235-41. [DOI: 10.1111/hdi.12357] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- May Yau
- Clinical Operations; Outset Medical, Inc.; San Jose California USA
| | - Michelle Carver
- Clinical Operations; Outset Medical, Inc.; San Jose California USA
| | - Luis Alvarez
- Division of Nephrology; Department of Medicine and Nephrology; Palo Alto Medical Foundation; Palo Alto California USA
| | | | - Glenn M. Chertow
- Division of Nephrology; Department of Medicine and Nephrology; Stanford University School of Medicine; Stanford California USA
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Abstract
PURPOSE OF REVIEW To discuss the changing landscape of home dialysis in the United States over the past decade, including recent research on clinical outcomes in patient undergoing peritoneal dialysis and home hemodialysis, and to describe the impact of recent payment reforms for patients with end-stage renal disease. RECENT FINDINGS Accumulating evidence supports the conclusion that clinical outcomes for patients treated with peritoneal dialysis or home hemodialysis are as good as or better than for patients treated with conventional in-center hemodialysis. The recent implementation of the Medicare-expanded prospective payment system for the care of end-stage renal disease patients has resulted in substantial growth in the utilization of peritoneal dialysis in the United States. Utilization of home hemodialysis has also grown, but the contribution of the expanded prospective payment system to this growth is less certain. SUMMARY Home dialysis, including peritoneal dialysis and home hemodialysis, represents an important alternative to in-center hemodialysis that is effective and patient-centered. Over the coming decade, the growth in the number of end-stage renal disease patient treated with home dialysis modalities should prompt further comparative and cost-effectiveness research, increased attention to racial and ethnic disparities, and investments in home dialysis education for both patients and providers. VIDEO ABSTRACT http://links.lww.com/CONH/A13.
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Jayanti A, Foden P, Wearden A, Morris J, Brenchley P, Mitra S. Self-cannulation for haemodialysis: patient attributes, clinical correlates and self-cannulation predilection models. PLoS One 2015; 10:e0125606. [PMID: 25992775 PMCID: PMC4437898 DOI: 10.1371/journal.pone.0125606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 03/24/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES With emerging evidence in support of home haemodialysis (HHD), patient factors which determine uptake of the modality need to be better understood. Self-cannulation (SC) is a major step towards enabling self-care 'in-centre' and at home and remains the foremost barrier to its uptake. Human factors governing this aspect of HD practice are poorly understood. The aim of this study is to better understand self-cannulation preferences and factors which define them in end stage renal disease (ESRD). DESIGN In this multicentre study, 508 of 535 patients from predialysis (Group A: n = 222), in-centre (Group B: n = 213), and home HD (Group C: n = 100) responded to a questionnaire with 3 self-cannulation questions. Simultaneously, data on clinical, cognitive and psychosocial variables were ascertained. The primary outcome measure was 'perceived ability to self-cannulate AV access'. Predictive models were developed using logistic regression analysis. RESULTS 36.6% of predialysis patients (A) and 29.1% of the 'in-centre' haemodialysis patients (B) felt able to consider SC for HD. Technical-skills related apprehension was highest in Group B (14.4%) patients. Response to routine venepuncture and the types of SC concerns were significant predictors of perceived ability to self-cannulate. There was no significant difference in concern for pain across the groups. In multivariable regression analysis, age, education level, 3 MS score, hypoalbuminemia in Groups B & C and additionally, attitude to routine phlebotomy and the nature of specific concern for self-cannulation in Groups A, B and C, are significant predictors of SC preference. The unadjusted c-statistics of models 1 (derived from Group A and validated on A) and 2 (derived from B+C and validated on B), are 0.76(95% CI 0.69, 0.83) and 0.80 (95% CI 0.74, 0.87) respectively. CONCLUSIONS There is high prevalence of perceived ability to self-cannulate. Modifiable SC concerns exist in ESRD. The use of predictive models to objectively define and target education and training strategies could potentially impact on HD self-management and future uptake of home HD.
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Affiliation(s)
- Anuradha Jayanti
- Department of Nephrology, Central Manchester Hospitals NHS Trust, Manchester, United Kingdom
- * E-mail:
| | - Philip Foden
- Department of Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Alison Wearden
- Department of Psychology, University of Manchester, Manchester, United Kingdom Investigators in the BASIC-HHD study group is provided in the Acknowledgments
| | - Julie Morris
- Department of Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Paul Brenchley
- Department of Nephrology, Central Manchester Hospitals NHS Trust, Manchester, United Kingdom
| | - Sandip Mitra
- Department of Nephrology, Central Manchester Hospitals NHS Trust, Manchester, United Kingdom
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Affiliation(s)
- John W. M. Agar
- Renal Unit; University Hospital; Barwon Health; Geelong Victoria Australia
| | - Dori Schatell
- CEO; Medical Education Institute; Madison Wisconsin USA
| | - Rachael Walker
- Nephrology; Hawkes Bay District Health Board; Hawkes Bay New Zealand
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Ferraresi M, Pia A, Guzzo G, Vigotti FN, Mongilardi E, Nazha M, Aroasio E, Gonella C, Avagnina P, Piccoli GB. Calcium-phosphate and parathyroid intradialytic profiles: A potential aid for tailoring the dialysate calcium content of patients on different hemodialysis schedules. Hemodial Int 2015; 19:572-82. [PMID: 25819092 DOI: 10.1111/hdi.12296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Severe hyperparathyroidism is a challenge on hemodialysis. The definition of dialysate calcium (Ca) is a pending issue with renewed importance in cases of individualized dialysis schedules and of portable home dialysis machines with low-flow dialysate. Direct measurement of calcium mass transfer is complex and is imprecisely reflected by differences in start-to-end of dialysis Ca levels. The study was performed in a dialysis unit dedicated to home hemodialysis and to critical patients with wide use of daily and tailored schedules. The Ca-phosphate (P)-parathyroid hormone (PTH) profile includes creatinine, urea, total and ionized Ca, albumin, sodium, potassium, P, PTH levels at start, mid, and end of dialysis. "Severe" secondary hyperparathyroidism was defined as PTH > 300 pg/mL for ≥3 months. Four schedules were tested: conventional dialysis (polysulfone dialyzer 1.8-2.1 m(2) ), with dialysate Ca 1.5 or 1.75 mmol/L, NxStage (Ca 1.5 mmol/L), and NxStage plus intradialytic Ca infusion. Dosages of vitamin D, calcium, phosphate binders, and Ca mimetic agents were adjusted monthly. Eighty Ca-P-PTH profiles were collected in 12 patients. Serum phosphate was efficiently reduced by all techniques. No differences in start-to-end PTH and Ca levels on dialysis were observed in patients with PTH levels < 300 pg/mL. Conversely, Ca levels in "severe" secondary hyperparathyroid patients significantly increased and PTH decreased during dialysis on all schedules except on Nxstage (P < 0.05). Our data support the need for tailored dialysate Ca content, even on "low-flow" daily home dialysis, in "severe" secondary hyperparathyroid patients in order to increase the therapeutic potentials of the new dialysis techniques.
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Affiliation(s)
- Martina Ferraresi
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Anna Pia
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Gabriella Guzzo
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Federica Neve Vigotti
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Elena Mongilardi
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Marta Nazha
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Emiliano Aroasio
- Laboratory, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Cinzia Gonella
- Laboratory, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
| | - Paolo Avagnina
- Dietetics and Clinical Nutrition, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Nephrology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Torino
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Walker RC, Hanson CS, Palmer SC, Howard K, Morton RL, Marshall MR, Tong A. Patient and Caregiver Perspectives on Home Hemodialysis: A Systematic Review. Am J Kidney Dis 2015; 65:451-63. [DOI: 10.1053/j.ajkd.2014.10.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/19/2014] [Indexed: 11/11/2022]
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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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Liu FX, Treharne C, Culleton B, Crowe L, Arici M. The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis. BMC Nephrol 2014; 15:161. [PMID: 25278356 PMCID: PMC4194367 DOI: 10.1186/1471-2369-15-161] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 09/25/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer. METHODS A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population. RESULTS Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years. CONCLUSION This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while limiting the impact on the dialysis budget. Increasing the usage of PD to 20-25%, the levels observed in 2005-2008, will totally offset the additional costs and generate further savings.
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Affiliation(s)
| | | | - Bruce Culleton
- />Baxter Healthcare Corporation, One Baxter Parkway, Deerfield, IL USA
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Mitra S, Jayanti A. Clinical outcomes and quality of life for home haemodialysis patients. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/jorn.2014.6.5.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sandip Mitra
- Consultant Nephrologist, Manchester Royal Infirmary and Senior Lecturer, University of Manchester
| | - Anuradha Jayanti
- Clinical Research Fellow, Department of Nephrology, Manchester Royal Infirmary
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Cornelis T, Tennankore KK, Goffin E, Rauta V, Honkanen E, Őzyilmaz A, Thanaraj V, Jayanti A, Mitra S, van der Sande FM, Kooman JP, Chan CT. An international feasibility study of home haemodialysis in older patients. Nephrol Dial Transplant 2014; 29:2327-33. [DOI: 10.1093/ndt/gfu260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] 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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Mishra RK, Dubin RF. The effects of frequent hemodialysis on left ventricular mass, volumes, and geometry. Clin J Am Soc Nephrol 2013; 8:2025-7. [PMID: 24235288 DOI: 10.2215/cjn.10611013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Rakesh K Mishra
- University of California, San Francisco, San Francisco, California, San Francisco Veterans Affairs Medical Center, San Francisco, California
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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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Chazot C, Ok E, Lacson E, Kerr PG, Jean G, Misra M. Thrice-weekly nocturnal hemodialysis: the overlooked alternative to improve patient outcomes. Nephrol Dial Transplant 2013; 28:2447-55. [DOI: 10.1093/ndt/gft078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Young BA, Chan C, Blagg C, Lockridge R, Golper T, Finkelstein F, Shaffer R, Mehrotra R. How to overcome barriers and establish a successful home HD program. Clin J Am Soc Nephrol 2012; 7:2023-32. [PMID: 23037981 PMCID: PMC3513750 DOI: 10.2215/cjn.07080712] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 08/18/2012] [Indexed: 11/23/2022]
Abstract
Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.
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Affiliation(s)
- Bessie A Young
- Veterans Affairs Puget Sound Health Care System, Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington 98108, USA.
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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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Lockridge R, Ting G, Kjellstrand CM. Superior patient and technique survival with very high standard Kt/V in quotidian home hemodialysis. Hemodial Int 2012; 16:351-62. [PMID: 22536789 DOI: 10.1111/j.1542-4758.2012.00696.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We studied the association of patient and dialysis factors with patient and technique survival in a cohort of all of our 191 of patients surviving >3 months on quotidian home hemodialysis (QHHD). Eighty-one patients were on nocturnal QHHD and 110 on short -daily QHHD. Weekly dialysis time was 7.5-48 hours, single pool Kt/V was 0.38-4.5 per treatment, and weekly standardKt/V was 2.1-7.5. The association of 18 patient and dialysis variables with patient and technique survival was analyzed by Kaplan-Meier and Cox analyses. Ninety-nine patients (52%) remained on QHHD, 34 (18%) were transplanted, 31 (16%) returned to 3/week HD, and 27 (14%) died. The 5-year patient survival was 71% ± 6% (night: 79% ± 7%, day: 69% ± 9%, P = 0.002). The 5-year technique survival was 80% ± 4% (night: 93% ± 3%, day: 46% ± 17%, P = 0.001). In Cox analyses, patient survival was independently associated with standard Kt/V (hazard ratio [HR] = 0.29, P < 0.0001), graduating from high school (HS) (HR = 0.11, P = 0.0002), and use of graft/fistula (HR = 0.22, P = 0.007). Technique survival was independently associated with standard Kt/V (HR = 0.50, P = 0.0003) and start of QHHD after 2003 (HR = 0.18, P = 0.007). Every increase in standard Kt/V was associated with improved survival. The highest survival occurred when standard Kt/V exceeded 5.1, only possible when weekly dialysis hours exceed 35 hours. In QHHD, higher standard Kt/V, education, and subcutaneous access are associated with better patient survival and higher standard Kt/V and longer experience of center with better technique survival. There was no upper limit of standard Kt/V, where survival plateaus. The amount of minimally "adequate" dialysis should be much increased.
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Affiliation(s)
- Robert Lockridge
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
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Stokes JB. Peritoneal Dialysis Is Not a Superior Therapy to Hemodialysis: A Comparison. Blood Purif 2012; 33:160-4. [DOI: 10.1159/000334159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Curran SP, Chan CT. Intensive hemodialysis: normalizing the "unphysiology" of conventional hemodialysis? Semin Dial 2011; 24:607-13. [PMID: 22122548 DOI: 10.1111/j.1525-139x.2011.01010.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Interest in intensified hemodialysis (HD) regimens is increasing internationally, as there is growing evidence that they are associated with improved outcomes. Appreciation that conventional hemodialysis (CHD), delivered as 4-hour sessions three times a week, is not providing optimal physiological replacement of renal function has led to the development of intensified dialysis therapies. These include long intermittent hemodialysis typically lasting 6-8 hours and delivered three times a week, short daily hemodialysis, providing more frequent sessions 4-7 days a week lasting 2-3.5 hours, and nocturnal hemodialysis, performed 5-7 days a week for 6-8 hours. Studies evaluating outcomes from these programs have indicated superior results to those achieved with CHD, including favorable modifications of cardiovascular risk factors and improvements in a variety of clinical measures. The objective of this review is to present available evidence supporting the hypothesis that in an attempt to provide a "more normal physiology," intensified HD regimens achieve outcomes superior to those historically achieved with CHD.
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Affiliation(s)
- Simon P Curran
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Abstract
The recently concluded Frequent Hemodialysis Network (FHN) trials have demonstrated some striking and unexpected results. Both the daily arm and the nocturnal arm of the trial clearly demonstrated that frequent (daily or nightly) dialysis reduced blood pressure, reduced the number of antihypertensive medications, and reduced serum phosphorous concentration. One of the major questions addressed by these studies was the extent to which left ventricular mass was reduced by frequent dialysis. While the daily FHN trial showed a clear effect of frequent dialysis to reduce left ventricular mass, the nocturnal FHN trial produced inconclusive results. These apparently contradictory results are probably influenced by inadequate power and the somewhat skewed patient selection in the nocturnal arm. Patients in the nocturnal FHN trial had a shorter time on dialysis prior to enrollment, and greater residual renal function than did patients in the daily FHN trial. From a general perspective, it appears that there is minimal difference in the effect on left ventricular mass between frequent daily dialysis and nocturnal dialysis. The FHN trial was not designed to determine the effects of frequent dialysis on mortality. The analyses of this question using retrospective data strongly suggest that frequent dialysis prolongs life. The nephrology community now has the task to develop new ways to deliver improved therapy to patients on dialysis. This task will be challenging as resources for health care are constrained. New approaches to the care of such patients will be needed to realize the important conceptual advances embedded in the results of the FHN trials.
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Affiliation(s)
- John B Stokes
- Division of Nephrology, Department of Internal Medicine, University of Iowa Carver College of Medicine and Department of Veteran's Affairs Medical Center, Iowa City, Iowa, USA.
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Lacson E, Diaz-Buxo J. In-center nocturnal hemodialysis performed thrice-weekly--a provider's perspective. Semin Dial 2011; 24:668-73. [PMID: 22106828 DOI: 10.1111/j.1525-139x.2011.00998.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Favorable clinical outcomes related to morbidity, mortality, patient well-being, laboratory biomarkers, and medication use have been reported with in-center nocturnal hemodialysis (INHD); nevertheless, it is not entirely clear how much patient selection or physiologic mechanisms related to better fluid management and phosphorus (and calcium) metabolism may explain these outcomes. There are indications that INHD may be a preferred treatment option in specific cases, such as in patients with high interdialytic weight gain, poor tolerance to high ultrafiltration rate, hyperphosphatemia, or for those patients who work or go to school during the day. In the era of the new prospective payment system where quality standards become intertwined with reimbursement, an INHD program may be a useful method to help attain quality goals in facilities that have patients with unfavorable case-mix. The experience of the past decade has shown INHD to be safe and well tolerated by patients. The growth of INHD therapy is a testament to sustainability and feasibility of this treatment option. Prospective clinical trials are needed in this area. If the promise of INHD is fulfilled, it may also prove to be a valuable option for potential success of Accountable Care Organizations where providers need to assume responsibility for more patient-centered care and improvement in clinical outcomes. In summary, based on the current experience, INHD is a viable and valuable option as an additional, alternative hemodialysis (HD) regimen to conventional HD.
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Affiliation(s)
- Eduardo Lacson
- Fresenius Medical Care, North America, Waltham, Massachusetts 02451-1457, USA.
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Piccoli GB. The never-ending search for the perfect dialysis. Should we move from the best treatment to the best system? Nephrol Dial Transplant 2011; 26:1128-31. [PMID: 21460360 DOI: 10.1093/ndt/gfr123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lacson E, Brunelli SM. Hemodialysis Treatment Time: A Fresh Perspective. Clin J Am Soc Nephrol 2011; 6:2522-30. [DOI: 10.2215/cjn.00970211] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW The length of time (Td) required for adequate maintenance hemodialysis therapy is perceived as a substantial patient burden. Technological advancements have allowed shortening Td over the past three decades. However, failure to detect improved outcomes with higher dialysis dose has prompted renewed interest in the potential impact of longer Td. RECENT FINDINGS Ongoing trials are focused on increasing the frequency of treatments, although the feasibility of having most patients agreeing to more than five treatments per week remain doubtful. Furthermore, survival was better in short daily hemodialysis with Td of 180 vs. 90 min. Within thrice weekly dialysis, several recent epidemiological studies have shown improved survival associated with Td more than 4 h. Improved outcomes for long in-center nocturnal hemodialysis (6-8 h, 3×/week), similar to what has been performed in Tassin for the last 30 years, have also been reported. SUMMARY Compelling rationale and recent outcome data support use of longer Td. Improved management of salt and water may be the cause for the dissociation of dialysis time and small molecule clearance. In most industrialized countries, hemodialysis care systems in place have the capacity to accommodate it. Until such time that results from prospective randomized trials are available, we believe that physicians should prescribe and exert all efforts to convince thrice weekly hemodialysis patients to accept 4 h as minimum Td.
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