Frequent hemodialysis: a critical review

Burden, depression and anxiety effects on family caregivers of patients with chronic kidney disease in Greece: a comparative study between dialysis modalities and kidney transplantation

INTRODUCTION

Burden of caregivers is a status that was identified as a consequence of daily care. Anxiety and depression are probably related to complex tasks interwined with the care of a family member suffering from chronic kidney disease (CKD).

PURPOSE

To examine the experienced burden, anxiety and depression of Greek caregivers of patients with End-Stage CKD on dialysis as well as kidney transplant recipients (TX) in relation to their demographic profile and to compare among the groups.

METHODS

A total of 396 participants (198 couples of patients and caregivers) were recruited. Structured interviews and self-completed questionnaires were obtained from patients undergoing dialysis modalities as well as TX (28 peritoneal dialysis patients, 137 hemodialysis patients, 33 TX) and their caregivers. Zarit Burden Interview, Beck Depression Inventory and the Generalized Anxiety Disorder-2 scales were used as screening tools.

RESULTS

The majority of caregivers were females (67.2%), with a median age of 58 years. Total burden was indicated as mild to moderate (Mdn = 36 (24-51)). Caregivers of haemodialysis (HD) patients showed the highest burden (Mdn = 40 (26-53)) followed by peritoneal dialysis(PD) (Mdn = 29 (25-51)) and TX group (Mdn = 28 (21-43)) (p = 0.022). Caregivers' depression and anxiety were related to the type of patients' treatment, as well. Caregivers of HD and PD patients reported significantly higher depression (Mdn = 11 (5-18)) and anxiety scores (Mdn = 3 (2-5)) in comparison to TX caregivers (Mdn = 6 (2-13) and Mdn = 2 (2-4)) (p = 0.045 and p = 0.04, respectively).

CONCLUSION

Caregivers of TX patients appeared to have less burden, depression and anxiety levels compared with caregivers of patients on dialysis modalities. Caregivers' burden is significantly associated with anxiety, depressive symptoms, gender, duration of caregiving, educational level, financial status and caregivers' age.

Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability

As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.

Cardiovascular Benefits of Extended-Time Nocturnal Hemodialysis

Hemodialysis (HD) remains the most utilized treatment for End-Stage Kidney Disease (ESKD) globally, mainly as conventional HD administered in 4 h sessions thrice weekly. Despite advances in HD delivery, patients with ESKD carry a heavy cardiovascular morbidity and mortality burden. This is associated with cardiac remodeling, left ventricular hypertrophy (LVH), myocardial stunning, hypertension, decreased heart rate variability, sleep apnea, coronary calcification and endothelial dysfunction. Therefore, intensive HD regimens closer to renal physiology were developed. They include longer, more frequent dialysis or both. Among them, Nocturnal Hemodialysis (NHD), carried out at night while asleep, provides efficient dialysis without excessive interference with daily activities. This regimen is closer to the physiology of the native kidneys. By providing increased clearance of small and middle molecular weight molecules, NHD can ameliorate uremic symptoms, control hyperphosphatemia and improve quality of life by allowing a liberal diet and free time during the day. Lastly, it improves reproductive biology leading to successful pregnancies. Conversion from conventional to NHD is followed by improved blood pressure control with fewer medications, regression of LVH, improved LV function, improved sleep apnea, and stabilization of coronary calcifications. These beneficial effects have been associated, among others, with better extracellular fluid volume control, improved endothelial- dependent vasodilation, decreased total peripheral resistance, decreased plasma norepinephrine levels and restoration of heart rate variability. Some of these effects represent improvements in outcomes used as surrogates of hard outcomes related to cardiovascular morbidity and mortality. In this review, we consider the cardiovascular effects of NHD.

Removal of middle molecules with medium cutoff dialyzer in patients on short frequent hemodialysis

INTRODUCTION

Medium cutoff (MCO) membranes for hemodialysis (HD) remove more effectively large middle molecules than high-flux (HF) membranes. In patients on in-center short frequent HD regimen (5 sessions per week, 2 hours and 30 minutes per session) the effect of MCO on middle weight uremic toxins has not been elucidated.

METHODS

This retrospective study included 15 patients previously performing short frequent HD with HF dialyzer (HF-HD), that were switched to short frequent HD with MCO dialyzer (MCO-HD) for 2 months, and returned to HF-HD. The primary endpoint was the predialysis concentration of α1-acid glycoprotein during the different study phases. Secondary endpoints were predialysis concentration of other middle molecules, albumin, and assessment of the quality of life using the 36-item short-form health survey (SF-36).

FINDINGS

During MCO-HD phase there was a reduction in mean ± SD α1-acid glycoprotein concentration (98.71 ± 25.2 vs. 88.6 ± 24.6 mg/dL, P = 0.107), followed by an increment 2 months after returning to HF-HD (89.18 ± 26.12 vs. 97.33 ± 31.29 mg/dL, P = 0.002); however, only the second variation was statistically significant. MCO-HD provided lower median predialysis concentration of prolactin (16 [10.2-25.6] vs. 14.1 [11.7-34.8] ng/mL, P = 0.036). Single-pool Kt/V, standard Kt/V, predialysis β2-microglobulin, myoglobin, and SF-36 questionnaire remained stable during the first two phases (pre-MCO and MCO). β2-Microglobulin increased in the post-MCO phase (20.02 ± 8.14 vs. 21.27 ± 7.64 μg/mL, P = 0.000). Mean predialysis concentration of albumin reduced significantly from pre-MCO vs. MCO phases (39.9 ± 3.7 vs. 38.3 ± 3.3 g/L, P = 0.020) and rebounded significantly from MCO vs. post-MCO phases (38.7 ± 3.1 vs. 41.3 ± 3.0 g/L, P = 0.007).

DISCUSSION

In this retrospective analysis, short frequent MCO-HD promotes a reduction in prolactin, a middle weight uremic toxin, and trends toward a reduction in α1-acid glycoprotein. No patients developed hypoalbuminemia. These findings are encouraging and deserve investigation in prospective studies.

Benefits and risks of frequent or longer haemodialysis: weighing the evidence

Although the ability of individuals with end-stage renal disease to maintain body homoeostasis is equally impaired during all weekdays, conventional haemodialysis (HD) treatment is scheduled thrice weekly, containing two short and one long interdialytic interval. This intermittent nature of HD and the consequent fluctuations in volume, metabolic parameters and electrolytes have long been hypothesized to predispose to complications. Large observational studies link the first weekday with an increased risk of cardiovascular morbidity and mortality. Several schemes of frequent and/or longer, home or in-centre HD have been introduced, aiming to alleviate the above risks by both increasing total dialysis duration and reducing the duration of interdialytic intervals. Observational studies in this field have non-uniform results, showing that enhanced frequency in home (but not in-centre) HD is associated with reduced mortality. Evidence from the randomized Daily and Nocturnal Trials of the Frequent HD Network suggest the opposite, showing mortality benefits with in-centre daily but not with home nocturnal dialysis. Secondary analyses of these trials indicate that daily and nocturnal schedules do not have equal effects on intermediate outcomes. Alternative schemes, such as thrice weekly in-centre nocturnal HD or every-other-day HD, seem to also offer improvements in several intermediate endpoints, but need further testing with randomized trials. This review summarizes the effects of frequent and/or longer HD methods on hard and intermediate outcomes, attempting to provide a balanced overview of the field.

Microbubbles and Ultrasound: Therapeutic Applications in Diabetic Nephropathy

Diabetic nephropathy (DN) remains one of the most common causes of end-stage renal disease. Current therapeutic strategies aiming at optimization of serum glucose and blood pressure are beneficial in early stage DN, but are unable to fully prevent disease progression. With the limitations of current medical therapies and the shortage of available donor organs for kidney transplantation, the need for novel therapies to address DN complications and prevent progression towards end-stage renal failure is crucial. The development of ultrasound technology for non-invasive and targeted in-vivo gene delivery using high power ultrasound and carrier microbubbles offers great therapeutic potential for the prevention and treatment of DN. The promising results from preclinical studies of ultrasound-mediated gene delivery (UMGD) in several DN animal models suggest that UMGD offers a unique, non-invasive platform for gene- and cell-based therapies targeted against DN with strong clinical translation potential.

A Comparison of Clinical Parameters and Outcomes over 1 Year in Home Hemodialysis Patients Using 2008K@home or NxStage System One

The prevalence of home hemodialysis (HHD) in the United States is growing, driven in part by improvements in dialysis machines for home use. We assessed clinical parameters and outcomes in HHD patients using either Fresenius 2008K@home or NxStage System One over 1 year. Patients were 18 years or older and received HHD for ≥30 days between January 1, 2009, and June 30, 2010. A propensity score match was used to control for differences in baseline characteristics, and 2008K@home patients were stratified by frequency of use. Data for outcome measures were analyzed using generalized linear mixed models. Treatment frequency was lower for 2008K@home groups than System One. Mean standardized Kt/V (stdKt/V) was 2.75 for 2008K@home ≥3.5x/week users and 1.99 for System One users (p < 0.001). Erythropoiesis-stimulating agent use tended to be lower for patients using System One. There were no statistically significant differences across groups in serum albumin, calcium, phosphorus, hemoglobin, or parathyroid hormone levels, normalized protein catabolic rate, body mass index, number of hospitalizations, or hospitalized days. Clinical parameters and outcomes for HHD patients using 2008K@home and System One were largely equivalent, although 2008K@home use was associated with higher stdKt/V. Further studies will be required to establish whether these differences in stdKt/V relate to differences in technology, treatment schedule, or a combination thereof.

The Effects of Parenteral Amino Acid Therapy on Protein Carbamylation in Maintenance Hemodialysis Patients

OBJECTIVE

Protein carbamylation is a urea-driven post-translational protein modification associated with mortality in dialysis patients. Free amino acids (AAs) are competitive inhibitors of protein carbamylation and animal studies suggest increasing AA concentrations reduces carbamylation burden. We hypothesized that AA therapy in maintenance hemodialysis patients would reduce carbamylation, carrying the potential to improve clinical outcomes.

DESIGN

Prospective pilot clinical trial (NCT1612429).

SETTING

The study was conducted from March 2013 to March 2014 in outpatient dialysis facilities in the Boston metropolitan area.

SUBJECTS AND INTERVENTION

We enrolled 23 consecutively consenting hemodialysis subjects, infusing the first 12 individuals with 250 cc of AAs 3 times per week postdialysis over 8 weeks. The remaining 11 subjects served as controls.

MAIN OUTCOME MEASURE

Change in carbamylated albumin (C-Alb), a measure of total body carbamylation burden, between baseline and 8 weeks was the primary outcome.

RESULTS

The treated and control groups had similar clinical characteristics and similar baseline C-Alb levels (mean ± SE 9.5 ± 2.4 and 9.3 ± 1.3 mmol/mol, respectively; P = .61). The treated arm showed a significant reduction in C-Alb compared with controls at 4 weeks (8.4% reduction in the treated arm vs. 4.3% increase in controls; P = .03) and the effect was greater by 8 weeks (15% reduction in the treated vs. 1% decrease in controls; P = .01).

CONCLUSION

In this pilot study, AA therapy appeared safe and effective at reducing C-Alb levels in hemodialysis patients compared with no treatment. The impact of reduced protein carbamylation on clinical outcomes should be further investigated.

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.

Pro: Should we move to more frequent haemodialysis schedules?

Most end-stage renal disease patients on maintenance haemodialysis follow the typical schedule of three sessions per week, and thus remain outside dialysis for two short intervals (∼2 days in duration) and for a longer interval (∼3 days) at the end of each week. This pattern was historically enforced more due to calendar logistics and less due to factors related to health and disease. Therefore, it is long hypothesized that the intermittent nature of haemodialysis and the consequent shifts and fluctuations in volume status and metabolic parameters during the dialysis-free periods may pre-dispose patients to several complications. Recent large-scale observational studies in haemodialysis patients link the first week-day (including the last hours of the long interval and the subsequent dialysis session) with increased risk of cardiovascular morbidity and mortality. Previous observational studies support that enhanced-frequency home haemodialysis is associated with reduced risk of all-cause mortality, while randomized studies suggest that short-daily or alternate-day in-centre haemodialysis offer improvements in left ventricular hypertrophy, blood pressure, phosphorous homeostasis and other intermediate end points when compared with conventional thrice-weekly in-centre haemodialysis. This article summarizes available evidence relating long inter-dialytic intervals with elevated cardiovascular risk, potential mechanisms for this association and the main benefits of more frequent dialytic modalities.

Con: Frequent haemodialysis for all chronic haemodialysis patients

Frequent haemodialysis (HD) regimens have been proposed with the aim to improve survival and other important patient outcomes. They indeed avoid the long interdialytic interval and have been associated with some proven benefits, i.e. an improvement in blood pressure and phosphataemia control, a reduction in left ventricular mass and lower ultrafiltration rates. However, the actual impact of frequent HD regimens on survival is, at best, inconclusive and, at worse, harmful, and remains uncertain regarding nutritional status and anaemia control. Moreover, the higher rates of vascular access complications and more rapid development of anuria with frequent HD regimens are worrying. Frequent HD also considerably increases the burden for patients and their caregivers, logistics and costs, especially with in-centre frequent schedules. In our opinion, before increasing HD frequency, a number of underused strategies summarized in our review and able to improve patient tolerance and/or HD dose should be tested first, taking into account patient's characteristics and life expectancy. Frequent HD schedules should be reserved for selected cases, only after all other available options have failed.

Effects of frequent hemodialysis on perceived caregiver burden in the Frequent Hemodialysis Network trials

BACKGROUND AND OBJECTIVES

Patients receiving hemodialysis often perceive their caregivers are overburdened. We hypothesize that increasing hemodialysis frequency would result in higher patient perceptions of burden on their unpaid caregivers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In two separate trials, 245 patients were randomized to receive in-center daily hemodialysis (6 days/week) or conventional hemodialysis (3 days/week) while 87 patients were randomized to receive home nocturnal hemodialysis (6 nights/week) or home conventional hemodialysis for 12 months. Changes in overall mean scores over time in the 10-question Cousineau perceived burden scale were compared.

RESULTS

In total, 173 of 245 (70%) and 80 of 87 (92%) randomized patients in the Daily and Nocturnal Trials, respectively, reported having an unpaid caregiver at baseline or during follow-up. Relative to in-center conventional dialysis, the 12-month change in mean perceived burden score with in-center daily hemodialysis was -2.1 (95% confidence interval, -9.4 to +5.3; P=0.58). Relative to home conventional dialysis, the 12-month change in mean perceived burden score with home nocturnal dialysis was +6.1 (95% confidence interval, -0.8 to +13.1; P=0.08). After multiple imputation for missing data in the Nocturnal Trial, the relative difference between home nocturnal and home conventional hemodialysis was +9.4 (95% confidence interval, +0.55 to +18.3; P=0.04). In the Nocturnal Trial, changes in perceived burden were inversely correlated with adherence to dialysis treatments (Pearson r=-0.35; P=0.02).

CONCLUSION

Relative to conventional hemodialysis, in-center daily hemodialysis did not result in higher perceptions of caregiver burden. There was a trend to higher perceived caregiver burden among patients randomized to home nocturnal hemodialysis. These findings may have implications for the adoption of and adherence to frequent nocturnal hemodialysis.