Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal disease

Impact of haemodialysis hours on outcomes in older patients

AIM

Previous studies report an association between longer haemodialysis treatment sessions and improved survival. Worldwide, there is a trend to increasing age among prevalent patients receiving haemodialysis. This analysis aimed to determine whether the mortality benefit of longer haemodialysis treatment sessions diminishes with increasing age.

METHODS

This was a retrospective cohort study of people who first commenced thrice-weekly haemodialysis aged ≥65 years, reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry from 2005 to 2015, included from 90 days after dialysis start. The primary outcome was all-cause mortality. Cox regression analysis was performed with haemodialysis session duration the exposure of interest.

RESULTS

Of 8224 people who commenced haemodialysis as their first treatment for kidney failure aged ≥65 years during this period, 4727 patients died. Longer dialysis hours per session was associated with a decreased risk of death in unadjusted analyses [hazard ratio, HR, for ≥5 h versus 4 to <4.5 h: 0.81 (0.75-0.88, p < .001)]. Patients having longer dialysis sessions were younger but had greater co-morbidity. In an adjusted model including age and other variables, the survival benefit of longer hours was only partially attenuated [HR for previous comparison: 0.75 (0.69-0.82, p < .001)], and no interaction between age and hours was demonstrated (p = .89).

CONCLUSION

The apparent survival benefit associated with longer haemodialysis session length appears to be preserved in patients 65 years or older. In practice, the benefit of longer dialysis hours should be carefully weighed against other factors in this patient group.

Intérêts et limites de l’Hémodialyse Longue Nocturne

L’hémodialyse (HD) Longue Nocturne (HDLN) intermittente permet de combiner dialyse et sommeil. Ses avantages cliniques sont une vitesse d’ultrafiltration réduite, un meilleur contrôle de la volémie avec amélioration de la tolérance des séances et des performances cardiaques, une phosphatémie et des moyennes molécules mieux épurées et une meilleure survie dans les études de cohortes. La qualité de vie n’est pas altérée par la longueur des séances et elle s’améliore quand elle n’est pas optimale lors du transfert de l’HD standard vers l’HDLN. La qualité du sommeil n’est parfois perturbée mais elle n’est pas une cause importante de sortie du programme. La pérennité d’un programme d’HDLN passe par les volontés conjointes médicales et managériales, la sélection des patients stables, le respect des horaires et de la durée de séances, indispensable à la dialyse de sommeil. Les autorités de santé doivent jouer un rôle pour permettre cette modalité dans des conditions financières acceptables. L’information au patient de l’existence de l’HDLN avant le stade de la dialyse est essentielle, aidée par le témoignage des pairs. Les sociétés savantes doivent soutenir la recherche et l’information aux néphrologues. Enfin les conditions architecturales favorisant l’intimité et le sommeil sont une clé de réussite du programme.

Survival and predictors of mortality among chronic kidney disease patients on hemodialysis in Amhara region, Ethiopia, 2021

BACKGROUND

Despite the high economic and mortality burden of chronic kidney disease, studies on survival and predictors of mortality among patients on hemodialysis in Ethiopia especially in the Amhara region are scarce considering their importance to identify some modifiable risk factors for early mortality to improve the patient's prognosis. So, this study was done to fill the identified gaps. The study aimed to assess survival and predictors of mortality among end-stage renal disease patients on hemodialysis in Amhara regional state, Ethiopia, 2020/2021.

METHOD

Institution-based retrospective record review was conducted in Felege Hiwot, Gonder, and Gambi hospitals from March 5 to April 5, 2021. A total of 436 medical records were selected using a simple random sampling technique. A life table was used to estimate probabilities of survival at different time intervals. Multivariable cox regression was used to identify risk factors for mortality.

RESULT

Out of the 436 patients 153 (35.1%) had died. The median survival time was 345 days with a mortality rate of 1.89 per 1000 person-days (95%CI (1.62, 2.22)). Patients live in rural residences (AHR = 1.48, 95%CI (1.04, 2.12)), patients whose cause of CKD was hypertension (AHR = 1.49, 95%CI (1.01, 2.23)) and human immune virus (AHR = 2.22, 95%CI (1.41, 3.51)), and patients who use a central venous catheter (AHR = 3.15, 95%CI (2.08, 4.77)) had increased risk of death while staying 4 h on hemodialysis (AHR = 0.43, 95%CI (0.23, 0.80)) decreases the risk of death among chronic kidney disease patients on hemodialysis.

CONCLUSIONS

The overall survival rate and median survival time of chronic kidney disease patients on hemodialysis were low in the Amhara region as compared with other developing Sub-Saharan African counties.

The effect of thymopentin on immune function and inflammatory levels in end-stage renal disease patients with maintenance hemodialysis

OBJECTIVE

This study investigated and analyzed the effect of Thymopentin on immune function and inflammatory levels in end-stage renal disease (ESRD) patients who were undergoing maintenance hemodialysis.

METHODS

A total of 112 patients with ESRD on regular hemodialysi from May 2018 to October 2019 were chosen and classified into an observation group and a control group by a convenience sampling method, with 56 cases in each group. The control-group was treated with conventional therapy, and the observation-group was treated with thymic pentapeptide based on the conventional treatment. The two groups' improvements in inflammation level, immunological functioning and living quality before and after treatment were compared.

RESULTS

IL-6, IL-8, TNF-α, and hs-CRP levels in the observation group after treatment were (5.52±1.46) ng/L, (18.76±2.83) ng/L, (3.27±1.08) pmol/L and (24.12±2.96) mg/L respectively, which were lower than (6.68±1.51) ng/L, (24.12±2.96) ng/L, (5.13±1.15) pmol/L and (6.46±1.19) mg/L in the control group (t=4.133, 9.795, 8.828, 6.198; P<0.05). After treatment, SOD level in the observation-group was (115.52±9.46) u/mL, which was higher than that of (104.68±9.21) u/mL in the control group (t=6.144, P<0.05); and MDA in the observation-group was (4.06±0.83) u/mL, which was lower than that of (5.22±0.96) u/mL in the control group (t=6.840, P<0.05). In addition, CD3⁺ (68.25±12.54)%, CD4⁺ (49.17±6.23)%, and CD4⁺/CD8⁺ (1.95±0.37) in the observation group during post-intervention were higher than of the counterparts (62.61±10.23)%, (45.21±5.89)% (1.71±0.32) in the control group (t=2.608, 3.457, 4.807; P<0.05); while CD8⁺ in the observation group (20.14±5.25)% was lower than that in the control group (25.01±5.47)% (t=3.671; P<0.05). The SF-36 score in the observation group after treatment was (73.43±5.59) points, which was superior to the score (66.06±5.22) in the control group (t=7.211, P<0.05).

CONCLUSION

Thymopentin can greatly improve the micro-inflammatory state of ESRD patients with maintenance hemodialysis, thereby improving the patient's immune function and living quality.

[Prolonged hemodialysis: Rationale, practical organization, results]

In France, long nocturnal dialyses, eight hours three-times a week, are sparsely proposed. However, numerous studies reported that this specific type of dialysis is associated to better blood pressure control, better cardiac remodeling, better mineral and nutritional balance as well as better life quality and survival rate. MATERIAL AND METHODS: In this study, we aimed at quantifying the benefits, risks and obstacles of developing night dialysis and at describing the results of a program that took place in Rennes from 2002 to 2019. Data were collected between 2008 and 2014 for eighteen case-patients and were compared to thirty-six controls that underwent conventional dialysis. Patients were paired according sex, age and year of dialysis start. RESULTS: The median age for dialysis start was 47.5 years [27-60] with a male prevalence (5/1). After six months, a significant difference was reported for postdialytic, systolic and diastolic pressure (respectively 126±15 vs 139±21 [P=0.04] and 72±9 vs 81±14 [P=0.02]) despite an antihypertensive reduction ranging from 2.4±1.4 to 1.3±0.9 per day at six months and 0.7±0.9 at one year (P=0.02). An increase of nPCR was evidenced at 6 and 9 months (P=0.02). At the end of the study, the phosphate level was maintained for both cohorts at the expense of an increased consumption of phosphate binder for the long nocturnal dialysis group (P=0.025). As a whole, 61% of the patients that pursued long night dialysis maintained a professional activity compared to only 30% for the controls (P=0.04). This highlights the advantages of night dialysis for maintaining employment but also the bias that represents the employment status in observational study on this specific topic.

Nocturnal Hemodialysis: Why Aren't More People Doing It?

Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.

COVID-19 pandemic era: is it time to promote home dialysis and peritoneal dialysis?

The novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic in March 2020 by the World Health Organization. Older individuals and patients with comorbid conditions such as hypertension, heart disease, diabetes, lung disease, chronic kidney disease (CKD) and immunologic diseases are at higher risk of contracting this severe infection. In particular, patients with advanced CKD constitute a vulnerable population and a challenge in the prevention and control of the disease. Home-based renal replacement therapies offer an opportunity to manage patients remotely, thus reducing the likelihood of infection due to direct human interaction. Patients are seen less frequently, limiting the close interaction between patients and healthcare workers who may contract and spread the disease. However, while home dialysis is a reasonable choice at this time due to the advantage of isolation of patients, measures must be assured to implement the program. Despite its logistical benefits, outpatient haemodialysis also presents certain challenges during times of crises such as the coronavirus disease 2019 (COVID-19) pandemic and potentially future ones.

Survival of patients treated with extended-hours haemodialysis in Europe: an analysis of the ERA-EDTA Registry

Background

Previous US studies have indicated that haemodialysis with ≥6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients.

Methods

We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association–European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5–4 h/treatment), EHD (three times weekly, ≥6 h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders.

Results

From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.1 ± 0.8 h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 ± 0.2 h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62–0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71–0.90)].

Conclusions

EHD is associated with better survival in European patients treated with haemodialysis three times weekly.

Renal Association Clinical Practice Guideline on Haemodialysis

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

Survival Benefit of Maintained or Increased Body Mass Index in Patients Undergoing Extended-Hours Hemodialysis Without Dietary Restrictions

OBJECTIVE

Low body mass index (BMI) is a potential risk factor for mortality in patients on maintenance hemodialysis. This suggests the usefulness of BMI as a prognostic factor and implies the importance of nutritional status, inflammation, and oxidative stress, all of which affect BMI. We aimed to evaluate BMI changes over time and the mortality risk in patients undergoing a novel combination therapy consisting of an extended-hours hemodialysis protocol without dietary restrictions, which enabled sufficient nutrition.

DESIGN AND METHODS

This is a retrospective cohort study. Patients were divided into 2 groups based on BMI change (ΔBMI < 0, ΔBMI ≥ 0) between the 3rd and 12th month after transfer to the clinic. We studied the associations of BMI changes with all-cause mortality. Further subgroup analyses were performed using Cox models. We finally studied 187 patients who were receiving the combined therapy. The main outcome measure was all-cause mortality of the study group.

RESULTS

The median (interquartile range) follow-up time was 4.9 (3.0-8.6) years. Overall, 138 patients were in the ΔBMI ≥ 0 group. As per unadjusted and adjusted Cox models, maintained or increased BMI during this period was associated with hazard ratios of 0.45 (confidence interval 0.23-0.87, P < .05) and 0.35 (confidence interval 0.17-0.75, P < .01) for all-cause mortality, respectively. In the same group, maintained or increased BMI was found to be significantly associated with decreased mortality in female, older, and nondiabetic patients. The data indicated that diabetic status could have a modifying effect on the association between variation in BMI and mortality (P = .006).

CONCLUSIONS

Extended-hours hemodialysis without dietary restrictions led to a beneficial effect of maintenance or increase in BMI, especially in females, patients aged ≥65 years, and those without diabetic nephropathy, which could lead to prolonged survival.

Independent effect of haemodialysis session frequency and duration on survival in non-indigenous Australians on haemodialysis

BACKGROUND

End-stage kidney disease patients have increased mortality compared to the general population. Haemodialysis (HD) of more frequent and of longer duration has been proposed to improve survival but it remains unclear if this is attributed to increased frequency, duration, or both. We aimed to examine the independent effects of session frequency and duration on mortality in incident HD patients.

METHODS

A retrospective cohort study was performed using data from the Australian and New Zealand Dialysis and Transplant Registry examining non-Indigenous patients aged ≥18 years who initiated HD of ≥3 sessions/week in Australia from 2001 to 2015. Initial dialysis prescription was categorized as session duration >5 h/session compared to ≤5 h/session and session frequency as >3 sessions/week compared to 3 sessions/week. Survival analysis was performed using Cox regression analysis, with multivariable analysis controlling for available covariates.

RESULTS

We examined 16 944 patients of whom 757 (4.5%) received >3 sessions/week and 518 (3.1%) received >5 h/session. After controlling for frequency, patients initiated on HD sessions >5 h had a significantly reduced risk of mortality compared with patients with HD session ≤5 h (adjusted hazard ratio (HR) = 0.57; 95% confidence interval (CI) = 0.44-0.74). In contrast, patients initiated on >3 sessions/week of HD had a similar risk of death when compared with patients on 3 sessions/week of HD (adjusted HR = 0.97; 95% CI = 0.84-1.13), after controlling for duration. Limitations include potential residual confounding and changes in exposure over time.

CONCLUSION

Longer duration rather than increased frequency of treatment appears to reduce mortality in HD patients. This has implications for management and requires further study.

Use of vasopressor for dialysis-related hypotension is a risk factor for death in hemodialysis patients: Nationwide cohort study

Because hypotension during hemodialysis (HD) makes continuation of HD difficult and is associated with mortality, pressor approaches are necessary for patients with hypotension. However, the relationships between the pressor approaches and the risk of death have not been clarified yet. We analyzed data from a nationwide prospective cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (n = 29,309). The outcome was all-cause one-year death. The association between the use of pressor approaches and the outcome was examined using Cox proportional hazards models adjusted for baseline characteristics, propensity score matched analysis and Bayesian networks. The background features of the patients were as follows: male, 59.6%; average age, 64.5 ± 12.5 years; and patients with diabetes mellitus, 31.5%. The pressor group showed a higher risk of the outcome than the control group [adjusted hazard ratio (aHR) 1.33 (95% CI: 1.21, 1.47), p = 0.0001]. Propensity score matched analysis also showed that the matched-pressor group had a higher risk of the outcome than the matched-control group [aHR 1.30 (95% CI: 1.17, 1.45), p = 0.0001]. Moreover, the Bayesian network showed a direct causal relationship from the use of pressor approaches to the outcome. The use of oral vasopressors [aHR 1.20 (95% CI: 1.07, 1.35), p = 0.0018], intravenous injection of vasopressors [aHR 1.54 (95% CI: 1.32, 1.79), p = 0.0001] and normal saline [aHR 1.18 (95% CI: 1.05, 1.33), p = 0.0066] were associated with a high risk of the outcome. In conclusion, this study showed that the use of pressor approaches during HD may be an independent risk factor for death.

No Survival Benefit in Octogenarians and Nonagenarians with Extended Hemodialysis Treatment Time

BACKGROUND

The population of elderly end-stage renal disease patients initiating dialysis is rapidly growing. Although longer treatment is supposed to benefit for hemodialysis (HD) patients through more solute clearance and slower fluid removal, it is not yet clear how treatment session length affects mortality risk in octogenarians and nonagenarians.

METHODS

In a cohort of 112,026 incident HD patients between 2007 and 2011, we examined the association of treatment session length with all-cause mortality, adjusting for demographics and comorbid conditions. We also used restricted spline functions for age to evaluate continuous changes in the association of short (< 210 min) and extended (≥240 min) HD treatment (vs. 210 to < 240 min) with all-cause mortality over continuous age.

RESULTS

During the first 91 days of dialysis, patients aged ≥80 years tended to have the lowest treatment session length (median [interquartile range] 211 [193-230] min, r > 0.5). Longer treatment was associated with better survival in patients < 65 and 65 to < 80 years but not in octogenarians/nonagenarians. The association of extended treatment (≥240 min) with better survival was attenuated across age and not significant among patients aged ≥80 years with a hazard ratio of 1.10 (95% CI 0.99-1.20). Shorter treatment sessions (< 210 min) was associated with higher mortality across all age groups.

CONCLUSION

Extended HD was not associated with lower mortality among octogenarians and nonagenarians, while it was associated with better survival among younger patients. Further studies are needed to determine the optimal treatment session length in elderly incident HD patients.

End-Stage Kidney Disease in Patients With Autosomal Dominant Polycystic Kidney Disease: A 12-Year Study Based on the Canadian Organ Replacement Registry

Background:

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, with afflicted patients often progressing to end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT). As the timelines to ESKD are predictable over decades, it follows that ADPKD patients should be optimized regarding kidney transplantation, home dialysis therapies, and vascular access.

Objectives:

To examine the association of kidney transplantation, dialysis modalities, and vascular access in ADPKD patients compared with a matched, non-ADPKD cohort.

Setting:

Canadian patients from 2001-2012 excluding Quebec.

Patients:

All adult incident ESKD patients who received dialysis or a kidney transplant.

Measurements:

ADPKD as defined by the treating physician.

Methods:

ADPKD and non-ADPKD patients were propensity score (PS) matched (1:4) using demographics, comorbidities, and lab values. Conditional logistic regression and Cox proportional hazards models were used to examine associations with kidney transplantation (preemptive or any), dialysis modality (peritoneal, short daily, home, or in-center hemodialysis [HD]), vascular access (arteriovenous fistula [AVF], permanent or temporary central venous catheter [CVC]), and dialysis survival.

Results:

We matched 2120 ADPKD (99.9%) with 8283 non-ADPKD with no significant imbalances between the groups. ADPKD was significantly associated with preemptive kidney transplantation (odds ratio [OR] = 7.13, 95% confidence interval [CI] = 5.74-8.87), any kidney transplant (OR = 2.37, 95% CI = 2.14-2.63), and initial therapy of nocturnal daily HD (OR = 2.74, 95% CI = 1.38-5.44), whereas in-center intermittent HD was significantly less likely in the ADPKD population (OR = 0.59, 95% CI = 0.54-0.65). There was no difference in peritoneal dialysis (PD) as initial RRT but lower use of any PD among the ADPKD group (OR = 0.85, 95% CI = 0.77-0.95). ADPKD patients were significantly more likely to have an AVF (OR = 3.25, 95% CI = 2.79-3.79) and less likely to have either a permanent (OR 0.68, 95% CI 0.59-0.78) or temporary (OR = 0.49, 95% CI = 0.41-0.59) CVC as compared with the non-ADPKD cohort. Survival on either in-center HD or PD was better for ADPKD patients (HD: hazard ratio [HR] 0.48, 95% CI 0.44-0.53; PD: HR 0.73, 95% CI 0.60-0.88).

Limitations:

Conservative care patients were not captured; despite PS matching, the possibility of residual confounding remains.

Conclusions:

ADPKD patients were more likely to receive a kidney transplant, use home HD, dialyze with an AVF, and have better survival relative to non-ADPKD patients. Conversely, they were less likely to receive PD either as initial therapy or anytime during ESKD. This may be attributed to higher transplantation or clinical decision-making processes susceptible to education and intervention.

Long-term clinical parameters after switching to nocturnal haemodialysis: a Dutch propensity-score-matched cohort study comparing patients on nocturnal haemodialysis with patients on three-times-a-week haemodialysis/haemodiafiltration

OBJECTIVES

Nocturnal haemodialysis (NHD), characterised by 8-hour sessions ≥3 times a week, is known to improve clinical parameters in the short term compared with conventional-schedule haemodialysis (HD), generally 3×3.5-4 hours a week. We studied long-term effects of NHD and used patients on conventional HD/haemodiafiltration (HDF) as controls.

DESIGN

Four-year prospective follow-up of patients who switched to NHD; we compared patients with patients on HD/HDF using propensity score matching.

SETTING

28 Dutch dialysis centres.

PARTICIPANTS

We included 159 patients starting with NHD any time since 2004, aged 56.7±12.9 years, with median dialysis vintage 2.3 (0.9-5.1) years. We propensity-score matched 100 patients on NHD to 100 on HD/HDF.

PRIMARY AND SECONDARY OUTCOME MEASURES

Control of hypertension (predialysis blood pressure, number of antihypertensives), phosphate (phosphate, number of phosphate binders), nutritional status and inflammation (albumin, C reactive protein and postdialysis weight) and anaemia (erythropoiesis-stimulating agent (ESA) resistance).

RESULTS

Switching to NHD was associated with a non-significant reduction of antihypertensives compared with HD/HDF (OR <2 types 2.17, 95% CI 0.86 to 5.50, P=0.11); and a prolonged lower need for phosphate binders (OR <2 types 1.83, 95% CI 1.10 to 3.03, P=0.02). NHD was not associated with significant changes in blood pressure or phosphate. NHD was associated with significantly higher albumin over time compared with HD/HDF (0.70 g/L/year, 95% CI 0.10 to 1.30, P=0.02). ESA resistance decreased significantly in NHD compared with HD/HDF, resulting in a 33% lower ESA dose in the long term.

CONCLUSIONS

After switching to NHD, the lower need for antihypertensives, phosphate binders and ESA persists for at least 4 years. These sustained improvements in NHD contrast significantly with the course of these parameters during continued treatment with conventional-schedule HD and HDF. NHD provides an optimal form of dialysis, also suitable for patients expected to have a long waiting time for transplantation or those convicted to indefinite dialysis.

Extended hours hemodialysis and survival: extended hours, extended evidence?

Extended-hours hemodialysis presents another approach to the intensification of therapy for maintenance hemodialysis recipients. Smaller studies have demonstrated several potential benefits with this modality, but the impact on patient-centered outcomes has been unclear. We review the largest published study to compare survival among patients who received extended-hours hemodialysis with those who received conventional hemodialysis.