Nocturnal hemodialysis in australia

Daily hemodialysis practices in Australia/New Zealand and in France: a comparative cohort study

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.

Surface-Engineered Blood Adsorption Device for Hyperphosphatemia Treatment

Correspondence: Melanie S. Joy, PharmD, PhD, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutical Sciences, Mail Stop C238, Room V20-4108, 12850 East Montview Blvd, Aurora, CO 80045. Email: Melanie.Joy@ucdenver.edu The research employed surface engineering methods to develop, optimize, and characterize a novel textile-based hemoadsorption device for hyperphosphatemia in hemodialysis-dependent end-stage kidney disease. Phosphate adsorbent fabrics (PAFs) were prepared by thermopressing alumina powders to polyester filtration fabrics and treatment with trimesic acid (TMA). For static experiments, phosphate adsorption capacity in buffer solution, plasma, and blood were evaluated by submersing the PAFs in 100 ml. For dynamic experiments, PAFs were equipped in a device prototype and incorporated in a pump-driven circuit. Phosphates were determined by a colorimetric assay and an Ortho Clinical Diagnostics Vitros 5600 Integrated analyzer. The maximum loading amount of TMA-alumina on PAFs was approximately 35 g/m under 260°C processing temperature. Phosphate adsorption capacity increased with initial concentration. Adsorption isotherms from buffer demonstrated a maximum phosphate adsorption capacity of approximately 893 mg/m at 37.5°C, pH 7.4, with similar results from plasma and whole blood. Measured phosphate concentrations during simulations demonstrated a 42% reduction, confirming the high capacity of the PAFs for removing phosphate from whole blood. Results from the current study indicated that an alumina-TMA treated PAF can dramatically reduce phosphate concentrations from biological samples. The technology could potentially be used as a tunable adsorbent for managing hyperphosphatemia in kidney disease.

Risk of vascular access complications with frequent hemodialysis

Frequent hemodialysis requires using the vascular access more often than with conventional hemodialysis, but whether this increases the risk for access-related complications is unknown. In two separate trials, we randomly assigned 245 patients to receive in-center daily hemodialysis (6 days per week) or conventional hemodialysis (3 days per week) and 87 patients to receive home nocturnal hemodialysis (6 nights per week) or conventional hemodialysis, for 12 months. The primary vascular access outcome was time to first access event (repair, loss, or access-related hospitalization). Secondary outcomes were time to all repairs and time to all losses. In the Daily Trial, 77 (31%) of 245 patients had a primary outcome event: 33 repairs and 15 losses in the daily group and 17 repairs, 11 losses, and 1 hospitalization in the conventional group. Overall, the risk for a first access event was 76% higher with daily hemodialysis than with conventional hemodialysis (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.11-2.79; P=0.017); among the 198 patients with an arteriovenous (AV) access at randomization, the risk was 90% higher with daily hemodialysis (HR, 1.90; 95% CI, 1.11-3.25; P=0.02). Daily hemodialysis patients had significantly more total AV access repairs than conventional hemodialysis patients (P=0.011), with 55% of all repairs involving thrombectomy or surgical revision. Losses of AV access did not differ between groups (P=0.58). We observed similar trends in the Nocturnal Trial, although the results were not statistically significant. In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.

Blood access in daily hemodialysis

Frequent dialyses are sometimes perceived as increasing the risk of blood access malfunction and decreased longevity. This review of the literature, however, indicates that the failure rates and overall fistula survival appear to be better with more frequent dialyses than with routine dialysis frequency, although the reasons for this phenomenon are not clear. One of the possible explanations is that frequent dialyses are associated with fewer intradialytic hypotensive episodes, which are very detrimental to the blood access. Another possible explanation is the generally lower blood flow used with more frequent hemodialyses, particularly long nocturnal hemodialysis. Finally, a decreased clotting tendency and decreased rates of hematoma formation at the puncture sites are additional possible explanations. Complication rates with bridge grafts are not higher with more frequent compared to routine thrice-weekly hemodialysis sessions. No such comparative data are available, however, for central-vein catheters. This lack of comparisons seems to stem from the intuitive assumption by nephrologists that hemodialyses that are more frequent should not adversely impact catheter complication rates and survival. No data at all are available on the use of the Dialock(R) hemodialysis system (Biolink Corp., Norwell, MA, USA) and LifeSite hemodialysis access system (Vasca, Inc., Tewksbury, MA, USA), two newer forms of hybrid access in patients undergoing frequent hemodialyses. Current evidence shows that the perceived risk of blood access malfunction and decreased longevity when patients undergo more frequent hemodialysis is not supported by the current literature.

Using water wisely: New, affordable, and essential water conservation practices for facility and home hemodialysis

Despite a global focus on resource conservation, most hemodialysis (HD) services still wastefully or ignorantly discard reverse osmosis (R/O) "reject water" (RW) to the sewer. However, an R/O system is producing the highly purified water necessary for dialysis, it rejects any remaining dissolved salts from water already prefiltered through charcoal and sand filters in a high-volume effluent known as RW. Although the RW generated by most R/O systems lies well within globally accepted potable water criteria, it is legally "unacceptable" for drinking. Consequently, despite being extremely high-grade gray water, under current dialysis practices, it is thoughtlessly "lost-to-drain." Most current HD service designs neither specify nor routinely include RW-saving methodology, despite its simplicity and affordability. Since 2006, we have operated several locally designed, simple, cheap, and effective RW collection and distribution systems in our in-center, satellite, and home HD services. All our RW water is now recycled for gray-water use in our hospital, in the community, and at home, a practice that is widely appreciated by our local health service and our community and is an acknowledged lead example of scarce resource conservation. Reject water has sustained local sporting facilities and gardens previously threatened by indefinite closure under our regional endemic local drought conditions. As global water resources come under increasing pressure, we believe that a far more responsible attitude to RW recycling and conservation should be mandated for all new and existing HD services, regardless of country or region.

Review Article: is it time to embrace haemodiafiltration for centre-based haemodialysis?

Improvements in survival in dialysis patients over the past few decades have been disappointing. Recent prospective trials such the haemodialysis study have not shown conclusive improvements. Two recent observational studies have found a striking survival advantage for haemodiafiltration (HDF). This review covers the differences between HDF and conventional haemodialysis (HD) and the history of the technological advances in the HDF technique. In addition, it explores the putative benefits of HDF over HD. While the observational studies provide a basis for optimism that HDF will provide benefit to dialysis patients, definitive conclusions cannot be drawn until the results of randomized controlled trials are available. While the evidence in favour of HDF at this stage is observational only, there are no studies suggesting that the treatment is detrimental. The use of HDF should probably be increased, particularly in centres where an increase in the frequency and duration of dialysis cannot be readily achieved.

Comparison of biochemical, haematological and volume parameters in two treatment schedules of nocturnal home haemodialysis

BACKGROUND

The biochemical, haemodynamic, clinical and nutritional benefits of nocturnal home haemodialysis (NHHD) compared with 4 h, three times per week conventional haemodialysis are well known and accrue by increasing dialysis time and frequency either for 8 h alternate night per week (NHHD3.5) or for 8 h six nights per week (NHHD6). However, there are little data comparing NHHD3.5 with NHHD6.

METHOD AND RESULTS

Thirteen patients on NHHD6 were compared with 21 patients on NHHD3.5, all with similar demographic profiles. Pre- and post-dialysis phosphate (PO4) control was ideal between the groups. However, all NHHD6 needed PO4 supplementation compared with 4/21 (19%) NHHD3.5. In the present study, 8/21 (38%) NHHD3.5 needed PO4 binders whereas none was required with NHHD6. The pre-haemoglobin (Hb) 122.8 g/L (NHHD6) versus 124.9 g/L (NHHD3.5) and the pre-albumin 38.31 g/L (NHHD6) versus 37.71 g/L (NHHD3.5) were not significantly different. NHHD6 had significantly lower pre-blood urea and creatinine (10.16 vs 19.54 mmol/L and 437.0 vs 812.3 micromol/L, respectively). Less interdialytic urea and creatinine fluctuation were also noted in NHHD6. Of major significance was the significantly lower ultra filtration rate and intradialytic weight gains (mean +/- SEM) of NHHD6 (249 +/- 76 mL/h and 2.0 +/- 0.65 kg) versus NHHD3.5 (425 +/- 168 mL/h and 2.9 +/- 1.2 kg).

CONCLUSION

The authors conclude that NHHD6 offers the optimum biochemical, volume and clinical outcome, but NHHD3.5 has additional appeal to providers seeking home-based therapy cost advantages and consumable expenditure control. A flexible dialysis programme should offer all the time and frequency options of NHHD but in particular, should support NHHD at a frequency sympathetic to the clinical rehabilitation and lifestyle aspirations of individual patients.

Nocturnal haemodialysis: an Australian cost comparison with conventional satellite haemodialysis

Dialysis is an expensive therapy, particularly considering its recurrent, protracted nature while patient numbers are also increasing. To afford dialysis for those in need, smarter, more efficient use of limited funds is mandatory. Newer techniques and improved equipment now permit safe, highly effective haemodialysis (HD) at home, alone and while asleep. Indeed, the increase in treatment hours and frequency achieved through nocturnal HD both increase HD efficiency and reduce cardiovascular stress when comparing nocturnal HD (6 nights/week for 8 h/treatment) to conventional daytime HD (4 h/treatment, three times/week). This study compares the expenditure of two distinct HD programmes in the same renal service during the Australian financial year 2003/2004. A conventional satellite HD unit (SHDU) and a nocturnal home HD programme (NHHD(6)) are compared, with both programmes 'notionalised' to 30 patients. The state-derived funding models under which these programmes operate are explained. All wage costs, recurrent expenditure, fixed costs and the estimated costs of building and infrastructure are included. The total NHHD(6) programme expenditure was 33,392 Australian dollars/patient per year (103.82 Australian dollars/treatment) and was 3,892 Australian dollars/patient per year less (a 10.75% saving) when compared with the SHDU expenditure of 36,284 Australian dollars/patient per year (232.58 Australian dollars/treatment). This represented an annual 116,750 Australian dollars programme saving for a 30 patient cohort. Potential additional NHHD(6) savings in erythropoietin, hospitalization and social security dependence were also identified. Home-based therapies are clinically sound, effective and fiscally prudent and efficient. Funding models should reward home-based HD. Health services should encourage home training and support systems, sustaining patients at home wherever possible.

'Flexible' or 'lifestyle' dialysis: Is this the way forward?

BACKGROUND

Despite the advent of two new dialysis options, nocturnal home haemodialysis and short daily haemodialysis, many units are yet to build them into the modalities on offer to end-stage renal failure patients. The reasons behind this inertia are complex but primarily include anxieties about workload, budgetary implications and outcome data.

METHOD

The Geelong dialysis programme, where both nocturnal home haemodialysis and short daily haemodialysis are offered, is compared with Australian and New Zealand national profiles.

RESULTS

Significant profile differences emerge when comparing sessions/week and h/week between the three groups. Most Australian (92.93%) and New Zealand (95.07%) haemodialysis patients dialyse for three sessions/week. This contrasts to Geelong where only 73.6% dialyse for three sessions/week. 18.8% of Geelong haemodialysis patients versus 1.8% (Australia) and 0.9% (New Zealand) dialyse for five or more sessions/week. Australia and New Zealand follow similar h/session patterns although more Australians (44.2%) dialyse for 4 h and fewer (24.2%) for 5 h than their New Zealand counterparts (39.6% and 29.8%, respectively), and few dialyse outside the 3.5-5 h window. In contrast, 6.7% of Geelong patients dialyse for 2-2.5 h/session versus Australia (0.9%) and New Zealand (0.2%). This represents the Geelong short daily dialysis programme. More Geelong patients (>15%) dialyse >/=8 h/week and represent the Geelong nocturnal home haemodialysis programme.

CONCLUSION

The flexible Geelong programme has been supported without exceeding the budget applied to a conventional dialysis programme with the same patient numbers.

Intradialytic serum protein concentrations differ between nightly nocturnal and conventional haemodialysis

AIM

Nocturnal haemodialysis (NHD) is a new haemodialysis (HD) modality that has been shown to have many benefits when compared with conventional haemodialysis (CHD). Previous results from our NHD programme have demonstrated a 7% fall in the postdialysis serum albumin concentration when compared with the pre-HD levels. A similar, physiological, 9% haemodilution of albumin is seen in normal individuals on assuming a supine posture.

METHOD

In this observational study, the intradialytic change in the concentration of 11 serum proteins (total protein, albumin, alkaline phosphatase, gamma glutamyl transferase, alanine transaminase, amylase, transferrin, complement factors 3 and 4, free thyroxine and C-reactive protein (CRP)) was measured in 10 patients on NHD and in 10 age- and sex-matched controls on CHD. The ultrafiltration rate (UFR) was also recorded.

RESULTS

We demonstrated an intradialytic fall in the total protein (0.63%), albumin (2.40%), alkaline phosphatase (1.84%), amylase (8.82%), complement factor 3 (2.73%) and CRP (8.19%) in patients on NHD. This was of a lesser magnitude than that occurring in the pilot study but still approximated the physiological fall in serum proteins occurring with overnight recumbency in normal individuals. In contrast, all serum proteins measured rose during CHD, reflecting intravascular volume contraction and haemoconcentration. The UFR was significantly lower in NHD than CHD (234.52+/-20.90 mL/h vs 435.38+/-38.44 mL/h, P<0.001).

CONCLUSION

We concluded that NHD is a modality that facilitates the use of a low UFR and hence the slow removal of volume which, in turn, results in a minimal perturbation of the normal recumbent volume distribution mechanism and the partial preservation of the normal physiological response to recumbency of the serum protein concentration.

Nocturnal haemodialysis in Australia and New Zealand (Review Article)

Although early experience in Australia and New Zealand confirmed home haemodialysis to be well tolerated, effective and with lower morbidity and mortality compared with centre-based haemodialysis, the advent of ambulatory peritoneal dialysis and 'satellite' haemodialysis has led to a steadily declining home haemodialysis population. However, the emergence of nocturnal haemodialysis, as a safe and highly effective therapy, has added to the modality choices now available and offers a new, highly attractive home-based option with many advantages over centre-based dialysis. For the patient, nocturnal haemodialysis means fluid and dietary freedom, less antihypertensive medication, the abolition of phosphate binders, the return of daytime freedom and the capacity for full-time employment. Potential biochemical benefits include normalization of the blood urea, serum creatinine, albumin, beta(2) microglobulin, homocysteine and triglyceride levels and other nutritional markers. Improved quality of life and sleep patterns and a resolution of sleep apnoea have been shown. Left ventricular function has also shown marked improvement. For the provider, nocturnal home haemodialysis offers clear cost advantages by avoiding high-cost nursing and infrastructure expenditure. Although consumable and equipment costs are higher, the savings on wage and infrastructure far outweigh this added expenditure. These combined factors make nocturnal haemodialysis an irresistible addition to comprehensive dialysis services, both from a clinical outcome and fiscal perspective.

History of home haemodialysis in Australia (Review Article)

Australia has had an active and slowly expanding home haemodialysis programme; however, this has failed to expand as rapidly as some other methods of treatment of end-stage kidney disease. The technique in Australia has always been a derivative from overseas experience, rather than innovative. It received some minor initial support from the report issued in 1968 by an ad-hoc Committee of the National Health and Medical Research Council on Rationalization of Facilities for Organ Transplantation and Renal Dialysis, but was ultimately disadvantaged because the report promoted transplantation over dialysis to an extent that proved markedly disproportionate to the number of patients who, in succeeding decades, would need maintenance dialysis treatment rather than transplantation. Nevertheless, each state in Australia established home haemodialysis facilities, but major interstate variations occurred in the uptake of the modality. The subsequent development of continuous ambulatory peritoneal dialysis and limited care dialysis centres appeared to have an important negative impact on home haemodialysis, although the recent introduction of daily dialysis is likely to have a positive influence in the future.

Quotidian dialysis – update 2005

PURPOSE OF REVIEW

The interest in quotidian hemodialysis has increased further after the HEMO study reported that high-dose thrice-weekly hemodialysis failed to improve clinical outcomes. This, in combination with a significant volume of newly published data, made a review of the topic of quotidian hemodialysis timely.

RECENT FINDINGS

The published research has revealed further evidence of cardiovascular and quality-of-life improvements as well as financial benefits with quotidian hemodialysis. Accrued worldwide experience has confirmed the previously published benefits of quotidian hemodialysis. There has been a significant effort by industry to produce patient-friendly machines for home hemodialysis. Reports on the use of daily hemodialysis and hemodiafiltration in children have appeared. An international registry of patients on quotidian hemodialysis has been created. The need for modification of the funding mechanisms and the lack of prospective randomized controlled studies on quotidian hemodialysis led to the funding of such studies by the National Institutes of Health in collaboration with Centers for Medicare and Medicaid services to be completed by 2008. The proper funding for daily home hemodialysis was secured in the province of British Columbia, Canada, and is under consideration elsewhere.

SUMMARY

There is increasing evidence confirming that quotidian hemodialysis improves clinical outcomes in a cost-efficient manner. Provided that the reimbursement issues are resolved these modalities may be utilized extensively at home as well as in the in-center facilities. The revitalization of home hemodialysis will compensate for the decline in utilization of continuous ambulatory peritoneal dialysis and the nursing shortage encountered in most countries.