Nightly home hemodialysis: outcome and factors associated with survival

Home versus in-centre haemodialysis for people with kidney failure

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Survival comparisons in home hemodialysis: Understanding the present and looking to the future

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.

Intensive Home Hemodialysis Survival Comparable to Deceased Donor Kidney Transplantation

Introduction

Kidney transplantation (KT) remains the treatment of choice for end-stage kidney disease (ESKD), but access to transplantation is limited by a disparity between supply and demand for suitable organs. This organ shortfall has resulted in the use of a wider range of donor kidneys and, in parallel, a reexamination of potential alternative renal replacement therapies. Previous studies comparing Canadian intensive home hemodialysis (IHHD) with deceased donor (DD) KT in the United States reported similar survival, suggesting IHHD might be a plausible alternative.

Methods

Using data from the Scientific Registry of Transplant Recipients and an experienced US-based IHHD program in Lynchburg, VA, we retrospectively compared mortality outcomes of a cohort of IHHD patients with transplant recipients within the same geographic region between October 1997 and June 2014.

Results

We identified 3073 transplant recipients and 116 IHHD patients. Living donor KT (n = 1212) had the highest survival and 47% reduction in risk of death compared with IHHD (hazard ratio [HR]: 0.53; 95% confidence interval [CI]: 0.34–0.83). Survival of IHHD patients did not statistically differ from that of DD transplant recipients (n = 1834) in adjusted analyses (HR: 0.96; 95% CI: 0.62–1.48) or when exclusively compared with marginal (Kidney Donor Profile Index >85%) transplant recipients (HR: 1.35; 95% CI: 0.84–2.16).

Conclusion

Our study showed comparable overall survival between IHHD and DD KT. For appropriate patients, IHHD could serve as bridging therapy to transplant and a tenable long-term renal replacement therapy.

Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study

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.

Weekly Standard Kt/Vurea and Clinical Outcomes in Home and In-Center Hemodialysis

BACKGROUND AND OBJECTIVES

Patients undergoing hemodialysis with a frequency other than thrice weekly are not included in current clinical performance metrics for dialysis adequacy. The weekly standard Kt/Vurea incorporates treatment frequency, but there are limited data on its association with clinical outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used multivariable regression to examine the association of dialysis standard Kt/Vurea with BP and metabolic control (serum potassium, calcium, bicarbonate, and phosphorus) in patients incidental to dialysis treated with home (n=2373) or in-center hemodialysis (n=109,273). We further used Cox survival models to examine the association of dialysis standard Kt/Vurea with mortality, hospitalization, and among patients on home hemodialysis, transfer to in-center hemodialysis.

RESULTS

After adjustment for potential confounders, patients with dialysis standard Kt/Vurea <2.1 had higher BPs compared with patients with standard Kt/Vurea 2.1 to <2.3 (3.4 mm Hg higher [P<0.001] for home hemodialysis and 0.9 mm Hg higher [P<0.001] for in-center hemodialysis). There were no clinically meaningful associations between dialysis standard Kt/Vurea and markers of metabolic control, irrespective of dialysis modality. There was no association between dialysis standard Kt/Vurea and risk for mortality, hospitalization, or transfer to in-center hemodialysis among patients undergoing home hemodialysis. Among patients on in-center hemodialysis, dialysis standard Kt/Vurea <2.1 was associated with higher risk (adjusted hazard ratio, 1.11; 95% confidence interval, 1.07 to 1.14) and standard Kt/Vurea ≥2.3 was associated with lower risk (adjusted hazard ratio, 0.97; 95% confidence interval, 0.94 to 0.99) for death compared with standard Kt/Vurea 2.1 to <2.3. Additional analyses limited to patients with available data on residual kidney function showed similar relationships of dialysis and total (dialysis plus kidney) standard Kt/Vurea with outcomes.

CONCLUSIONS

Current targets for standard Kt/Vurea have limited utility in identifying individuals at increased risk for adverse clinical outcomes for those undergoing home hemodialysis but may enhance risk stratification for in-center hemodialysis.

Choosing Home Hemodialysis: A Critical Review of Patient Outcomes

BACKGROUND/AIM

Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL).

METHODS

Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL.

RESULTS

Regarding mortality, 10 of 13 trials reported 13-52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body mass index in HHD vs. ICHD patients, while others found no significant differences. There were no significant differences in the rate of hospitalization between HHD and ICHD in the 6 articles reviewed. Seven studies on QoL demonstrated positive trends in HHD vs. ICHD populations.

CONCLUSIONS

Despite limitations in the current data, 66% of the publications reviewed (29/44) demonstrated improved clinical outcomes in patients who chose HHD. These include improved survival, CV, nutritional, and QoL parameters. Even though HHD may not be preferred in all patients, a review of the literature suggests that HHD should be provided as a modality choice for substantially more than the current 1.8% of HHD patients in the United States.

Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis

Background:

Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the comparative effectiveness of these modalities is unclear.

Objective:

We had the following aims: (1) to compare the association of mortality and hospitalization in patients undergoing intensive HD, compared with conventional HD or PD and (2) to appraise the methodological quality of the supporting evidence.

Data Sources:

MEDLINE, Embase, ISI Web of Science, CENTRAL, and nephrology conference abstracts.

Study Eligibility, Participants, and Interventions:

We included cohort studies with comparator arm, and randomized controlled trials (RCTs) with >50% of adult patients (≥18 years) comparing any form of intensive HD (>4 sessions/wk or >5.5 h/session) with any form of chronic dialysis (PD, HD ≤4 sessions/wk or ≤5.5 h/session), that reported at least 1 predefined outcome (mortality or hospitalization).

Methods:

We used the GRADE approach to systematic reviews and quality appraisal. Two reviewers screened citations and full-text articles, and extracted study-level data independently, with discrepancies resolved by consensus. We pooled effect estimates of randomized and observational studies separately using generic inverse variance with random effects models, and used fixed-effects models when only 2 studies were available for pooling. Predefined subgroups for the intensive HD cohorts were classified by nocturnal versus short daily HD and home versus in-center HD.

Results:

Twenty-three studies with a total of 70 506 patients were included. Of the observational studies, compared with PD, intensive HD had a significantly lower mortality risk (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.84; I² = 91%). Compared with conventional HD, home nocturnal (HR: 0.46; 95% CI: 0.38-0.55; I² = 0%), in-center nocturnal (HR: 0.73; 95% CI: 0.60-0.90; I² = 57%) and home short daily (HR: 0.54; 95% CI: 0.31-0.95; I² = 82%) intensive regimens had lower mortality. Of the 2 RCTs assessing mortality, in-center short daily HD had lower mortality (HR: 0.54; 95% CI: 0.31-0.93), while home nocturnal HD had higher mortality (HR: 3.88; 95% CI: 1.27-11.79) in long-term observational follow-up. Hospitalization days per patient-year (mean difference: –1.98; 95% CI: –2.37 to −1.59; I² = 6%) were lower in nocturnal compared with conventional HD. Quality of evidence was similarly low or very low in RCTs (due to imprecision) and observational studies (due to residual confounding and selection bias).

Limitations:

The overall quality of evidence was low or very low for critical outcomes. Outcomes such as quality of life, transplantation, and vascular access outcomes were not included in our review.

Conclusions:

Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD. As the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis. Practice guidelines that promote shared decision-making are likely to be helpful.

Current State and Future Trends to Optimize the Care of African Americans with End-Stage Renal Disease

BACKGROUND

Chronic kidney disease is a progressive disease, which terminates in end-stage renal diseases (ESRD) that requires either dialysis or kidney transplantation for the patient to survive. There is an alarming trend in the disparities of ESRD in African Americans (AAs). Currently, AAs represent more than 30% of incident ESRD cases, yet they constitute 15% of the overall US population. Despite the reductions in mortality, increases in access to patient-centered home dialysis and preemptive kidney transplantation for the overall US ESRD population over the last decade, disparities in the care of AAs with ESRD remain largely unaffected.

SUMMARY

This review discusses patient-, community-, and practitioner-related factors that contribute to disparities in ESRD care for AAs. In particular, the review addresses issues related to end-of-life support, the importance of Apolipoprotein-1 gene variants, and the advent of pharmacogenomics toward achieving precision care. The need for accessible clinical intelligence for the ESRD population is discussed. Several interventions and a call to action to address the disparities are presented. Key Messages: Significant disparities in ESRD care exist for AAs. Strategies to enhance patient engagement, education, accountable partnerships, and clinical intelligence may reduce these disparities.

Clinical, patient-related, and economic outcomes of home-based high-dose hemodialysis versus conventional in-center hemodialysis

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.

An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry)

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.

Home Hemodialysis Dose: Balancing Patient Needs and Preferences

<b><i>Background:</i></b> The aim in defining the dose of HHD is to provide sufficient dialysis required to possibly ‘normalize' all abnormalities associated with renal failure in order improve patient survival and quality of life. Much progress has been made in defining the dose required to accomplish this goal, but the evidence is still far from robust. The main limitations are incomplete understanding of uremic toxins, their relative importance in causing uremic symptoms, and our inability to comprehensively assess dry weight. <b><i>Summary:</i></b> This review provides guidance on realistic dosing of dialysis for the HHD patient based on the available evidence, where available, and alternative regimens that suit the individual's lifestyle and preferences. <b><i>Key Messages:</i></b> HHD can easily accommodate alternative, intensive HD prescriptions, including daily and nocturnal HD. HHD provides prescription flexibility to fulfill patient needs while taking their preferences into account.

Nephrologists' perspectives on dialysis treatment: results of an international survey

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.

Frequent hemodialysis: a critical review

Conventional, thrice-weekly hemodialysis (CHD) is the most commonly prescribed dialysis regimen. Despite widespread acceptance of CHD, long-term analyses of registry data have revealed an increased risk for mortality during the long 2-day interdialytic interval of thrice-weekly therapies. High mortality rates during this period suggest that there may be a role for more frequent HD in improving patient outcomes and survival through elimination of the long interdialytic period. Several regimens have been investigated including: short, daily HD, frequent nocturnal HD, and alternate-day HD. In this review, we provide an in-depth summary of current data comparing the effects of frequent and CHD modalities on survival, hospitalizations, vascular access complications, burden of therapy, quality of life, residual renal function, cardiovascular parameters, bone mineral metabolism, and anemia. Limitations of the data as well as the role of frequent dialysis in clinical practice are also discussed.

Excellent long time survival for Swedish patients starting home-hemodialysis with and without subsequent renal transplantations

Survival for patients on dialysis is poor. Earlier reports have indicated that home-hemodialysis is associated with improved survival but most of the studies are old and report only short-time survival. The characteristics of patient populations are often incompletely described. In this study, we report long-term survival for patients starting home-hemodialysis as first treatment and estimate the impact on survival of age, comorbidity, decade of start of home-hemodialysis, sex, primary renal disease and subsequent renal transplantation. One hundred twenty-eight patients starting home-hemodialysis as first renal replacement therapy 1971-1998 in Lund were included. Data were collected from patient files, the Swedish Renal Registry and Swedish census. Survival analysis was made as intention-to-treat analysis (including survival after transplantation) and on-dialysis-treatment analysis with patients censored at the day of transplantation. Ten-, twenty- and thirty-year survival were 68%, 36% and 18%. Survival was significantly affected by comorbidity, age and what decade the patients started home-hemodialysis. For patients younger than 60 years and with no comorbidities, the corresponding figures were 75%, 47% and 23% and a subsequent renal transplantation did not significantly influence survival. Long-term survival for patients starting home-hemodialysis is good, and improves decade by decade. Survival is significantly affected by patient age and comorbidity, but the contribution of subsequent renal transplantation was not significant for younger patients without comorbidities.

Superior patient and technique survival with very high standard Kt/V in quotidian home hemodialysis

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.

Nocturnal hemodialysis: analysis following the Frequent Hemodialysis Network trial

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.

Effect of pioglitazone on sciatic nerve ischemia/reperfusion injury in rats

OBJECTIVE

Evaluation of the effect of pioglitazone on sciatic nerve ischemia/reperfusion (I/R) injury in rat.

METHOD

Sixty rats were divided into 10 groups (n = 6). Treatment groups received 15 mg/kg pioglitazone intraperitoneally 1 h before induction of I/R by clamping the right common iliac and femoral arteries for 3 h. After certain time intervals of reperfusion (0 h, 3 h, 1, 4, and 7 days), the function of the hind limb was assessed using behavioral scores based on gait, grasp, paw position, and pinch sensitivity. The sciatic nerve was removed for light microscopy studies and graded for ischemic fiber degeneration (IFD) and edema. Plasma malondialdehyde (MDA) level was measured as an indicator of lipid peroxidation at the end of reperfusion intervals.

RESULT

Behavioral scores were improved in the pioglitazone groups just on the 4th and 7th days of reperfusion (p < 0.05). Comparison of the pioglitazone with the control groups showed significant differences in edema at 4 and 7 days. Although IFD decreased in the pioglitazone group at 7 days of reperfusion, it was not statistically significant. In addition, the MDA level was significantly lower in pioglitazone-treated groups.

CONCLUSION

Our results show the protective effect of pioglitazone on sciatic nerve I/R injury.