Scope and Design of the Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements (FREEDOM) Study

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.

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.

Comparison of physical activity and quality of life in home haemodialysis (HHD) patients versus conventional in-centre haemodialysis (ICHD) patients: the observational, longitudinal, prospective, international, multicentric SeCoIA study protocol

BACKGROUND

Home haemodialysis (HHD), has shown improved clinical outcomes, as well as a better quality of life, compared to conventional in-centre haemodialysis (ICHD) but still has a global low prevalence among end-stage renal disease patients. Haemodialysis (HD) patients tend to be sedentary but only few studies, mainly in North American ICHD patients, have evaluated the level of activity in HD patients.

METHODS

SeCoIA is an observational, longitudinal, prospective, international, multicentric, study, conducted in metropolitan France and Belgium. The main objective of the study is to quantify the physical activity measured by the total daily number of steps, in HHD patients compared to ICHD patients. The SeCoIA study will include 80 HHD patients and 80 ICHD patients,. Secondary objectives will be to characterize the HHD population and to confirm HHD efficiency on clinical parameters, as well as quality of life (QoL), in current practice. Physical activity will be measured by a 3-axis accelerometer. Accelerometers have been shown to provide accurate information, on both physical activity and sedentary behaviour. Patients will be instructed to wear the device and complete a patient diary 7 consecutive days after inclusion and the first week of each month for 12 months. Decision to undergo HDD or ICHD is independent of the study and follow-up frequency remains at the discretion of the physician/centre. QoL and quality of sleep will be respectively assessed by the Kidney Disease Quality of Life 1.2 (KDQOL™) and the Pittsburg Sleep Quality index (PSQI) questionnaires at inclusion, 6- and 12-month visits. Patients presenting a restless leg syndrome (RLS) will also complete the International Restless Legs Syndrome rating scale (IRLS) questionnaire.

DISCUSSION

The SeCoIA study will be the first large cohort study (160 patients) evaluating physical activity, objectively measured with a 3-axis accelerometer, in HHD versus ICHD patients. The present study will also include a comparison of QoL with a focus on RLS between HHD and ICHD. It is anticipated that HHD patients will have an improved physical activity and QoL which should encourage physicians to further promote HHD.

TRIAL REGISTRATION

Clinical trial NCT03737578 study registered on November 9, 2018 (Retrospectively registered).

Optimizing serum total carbon dioxide concentration during short and nocturnal frequent hemodialysis using lactate as dialysate buffer base

INTRODUCTION

Definitive clinical studies to determine the optimal dialysate lactate concentration to prescribe during frequent hemodialysis when using the NxStage System One dialysis delivery system at low dialysate flow rates have not been reported.

METHODS

We used clinical data from patients who transferred from in-center thrice-weekly hemodialysis (ICHD) to daily home hemodialysis using the NxStage System One and the H⁺ mobilization model to calculate acid generation rates in patient sub-groups during the FREEDOM study. Assuming those acid generation rates were representative, we then predicted using the H⁺ mobilization model the effect of using dialysate lactate concentrations of 40 and 45 mEq/L on predialysis serum total carbon dioxide (tCO₂ ) concentrations in patients who transfer from ICHD to short and nocturnal frequent hemodialysis prescriptions used in current clinical practice; the prescriptions evaluated varied by treatment frequency, dialysate volume per treatment, and treatment times.

FINDINGS

With frequencies of four to six treatments per week and treatment times of 170 to 210 minutes per treatment, the effect of dialysate lactate concentration was primarily dependent on weekly dialysate volume. For weekly dialysate volumes of 150 to 160 L per week, use of dialysate lactate concentrations of 45 mEq/L, but not 40 mEq/L, resulted in an increase of predialysis serum tCO₂ concentration. When longer treatment times typical of nocturnal frequent hemodialysis were evaluated, model predictions showed that the use of dialysate lactate concentration of 45 mEq/L may not be appropriate for many patients because of excessive increases in predialysis serum tCO₂ concentration. Reducing dialysate volume from 60 to 30 L may limit the increase in predialysis serum tCO₂ concentration when patients transfer from ICHD to nocturnal frequent hemodialysis.

DISCUSSION

Predictions from the H⁺ mobilization model show that dialysate lactate concentration and weekly dialysate volume are the primary prescription parameters for optimizing predialysis serum tCO₂ concentration during short and nocturnal frequent hemodialysis.

Effect of dialysate potassium and lactate on serum potassium and bicarbonate concentrations during daily hemodialysis at low dialysate flow rates

Background

Observational studies of hemodialysis patients treated thrice weekly have shown that serum and dialysate potassium and bicarbonate concentrations are associated with patient outcomes. The effect of more frequent hemodialysis on serum potassium and bicarbonate concentrations has rarely been studied, especially for treatments at low dialysate flow rate.

Methods

These post-hoc analyses evaluated data from patients who transferred from in-center hemodialysis (HD) to daily HD at low dialysate flow rates during the FREEDOM Study. The primary outcomes were the change in predialysis serum potassium and bicarbonate concentrations after transfer from in-center HD (mean during the last 3 months) to daily HD (mean during the first 3 months).

Results

After transfer from in-center HD to daily HD (data from 345 patients, 51 ± 15 years of age, mean ± standard deviation), predialysis serum potassium decreased (P < 0.001) by approximately 0.4 mEq/L when dialysate potassium concentration during daily HD was 1 mEq/L; no change occurred when dialysate potassium concentration during daily HD was 2 mEq/L. After transfer from in-center HD to daily HD (data from 284 patients, 51 ± 15 years of age), predialysis serum bicarbonate concentration decreased (P = 0.0022) by 1.0 ± 3.3 mEq/L when dialysate lactate concentration was 40 mEq/L but increased (P < 0.001) by 2.5 ± 3.5 mEq/L when dialysate lactate concentration was 45 mEq/L. These relationships were dependent on serum potassium and bicarbonate concentrations during in-center HD.

Conclusions

Control of serum potassium and bicarbonate concentrations during daily HD at low dialysate flow rates is readily achievable; the choice of dialysate potassium and lactate concentration can be informed when transfer is from in-center HD to daily HD.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1450-7) contains supplementary material, which is available to authorized users.

When is more frequent hemodialysis beneficial?

The use of frequent hemodialysis (HD) is growing, with the hope of improving outcomes in end-stage renal disease. We narratively review the three randomized trials, 15 comparative cohort studies, and several case series of frequent HD that empirically demonstrate the potential efficacy and adverse effects of these regimens. Taken together, the randomized studies suggest frequent HD may result in left ventricular mass regression. This effect is most pronounced when left ventricular mass is abnormal, but attenuated by significant residual urine output. Both frequent short and long HD consistently improved blood pressure control and reduced antihypertensive use, despite greater weekly interdialytic weight gains. Serum phosphate was lowered. Frequent short daytime HD improved health-related quality of life, while frequent long overnight HD did not. Regarding adverse effects, frequent HD patients underwent significantly more procedures to salvage arteriovenous vascular accesses. An absolute increase in hypotensive episodes was observed with frequent short HD, while frequent long HD accelerated residual renal function loss and increased perceived caregiver burden. The effect of frequent HD on mortality is controversial, due to conflicting results and limitations of published studies. Finally, pregnancy outcomes may be substantially better with frequent long HD. On the basis of these data, we suggest frequent HD is most likely to benefit patients with left ventricular hypertrophy particularly if there is minimal urine output, those unable to attain dry weight on a thrice weekly schedule, and pregnant women. All patients receiving frequent HD should be advised of and monitored for potential risks.

Phosphate and Calcium Control in Short Frequent Hemodialysis with the NxStage System One Cycler: Mass Balance Studies and Comparison with Standard Thrice-Weekly Bicarbonate Dialysis

BACKGROUND

Short frequent dialysis with NxStage System One cycler (NSO) has become increasingly popular as home hemodialysis prescription. Short dialysis sessions with NSO might not allow adequate phosphate (P) removal.

METHODS

Single-session and weekly balances of P and calcium (Ca) were compared in 14 patients treated with NSO (6 sessions/week) and in 14 patients on standard bicarbonate dialysis (BHD).

RESULTS

NSO and BHD showed similar plasma P fall, with end-dialysis plasma P slightly lower in BHD (2.2 ± 0.5 vs. 2.7 ± 0.8 mg/dL, p < 0.02). Single-session P removal was lower in NSO, but weekly removal was higher (3,488 ± 1,181 mg vs. 2,634 ± 878, p < 0.003). Plasma Ca increase was lower in NSO, with similar PTH fall. Ca balance varied according to start plasma Ca, dialysate to blood Ca gradient and net ultrafiltration.

CONCLUSIONS

short, frequent home hemodialysis with NSO, on a 6/week-based prescription, allows higher weekly P removal than BHD. With the dialysate Ca concentration in use (6 mg/dL), total plasma Ca and iCa concentration increase is lower in NSO.

Survival by Dialysis Modality-Who Cares?

In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades.

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.

Home haemodialysis: trends in technology

Self management and home-based dialysis therapies offer the prospect of improved patient experience and outcomes. To allow more patients to realize these benefits requires changes in technology which focus on maximizing the ease and minimizing the burdens of undertaking home dialysis. These developments are underway.

Time to recovery after a hemodialysis session: impact of selected variables

Background

Patients maintained on hemodialysis (HD) have an impaired health-related quality of life (HRQOL). One factor that has been suggested to contribute to this impairment is the prolonged recovery time after completing a conventional HD session. The present study was designed to carefully examine the time to recovery (TTR) in patients maintained on three times/week conventional HD and evaluate the clinical and demographic features associated with the TTR.

Methods

Two hundred and sixty-seven patients on conventional three times/week HD were studied during three successive HD treatments. Patients were asked how long it took them to recover from their previous session. Detailed demographic and clinical data as well as data involving the most recent HD session were reviewed.

Results

The mean ± SD age was 66.4 ± 15.7 and the mean duration of renal replacement therapy was 40.1 ± 37.6 months. The mean time to recovery was 246 ± 451 min. A multivariate regression analysis including age, gender, number of comorbidities, months on renal replacement therapy, occurrence of hypotension during dialysis, amount of ultrafiltration and duration of dialysis session revealed that none of these covariates was significantly associated with TTR from HD.

Conclusions

The present study is important since it clarifies that the TTR after an HD session is not related to various demographic and clinical factors that one might have expected would impact on this variable.

Quality of life of chronic kidney disease patients in developing countries

In the developing world, the emphasis of care for the patient with chronic kidney disease is, in general, focused on the basics of care and patient survival; attention is not primarily focused on quality of life assessments. However, this arena is beginning to attract more attention. It is important to determine if standardized instruments are valid in the developing world and which unique assessments need to be utilized in individual cultural settings.

How to overcome barriers and establish a successful home HD program

Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.

Erythropoietic stimulating agents and quality of a patient's life: individualizing anemia treatment

Erythropoietic stimulating agents (ESAs) such as erythropoietin have been used for decades to treat the anemia of CKD. Clinical practice guidelines suggest target hemoglobin levels >10 g/dl, and average Hb levels have risen from 9.6 to 12.0 g/dl. Several studies have shown trends for higher mortality and myocardial infarction, higher BP, increased vascular access thrombosis, and strokes in patients treated to target Hb ≥13 g/dl. Patients with profound anemia suffer from symptoms of fatigue, poor energy, weakness, and shortness of breath. Such symptoms reported directly by patients, or patient-reported outcomes (PROs), may be a valuable tool to target ESA treatment in anemic CKD patients. Studies show that improvements in anemia correlate with improvements in these PRO domains in some individuals. We propose that instead of Hb targets for all patients, treatment of anemia should be directed toward improving the areas of patient-perceived quality of life most affected by anemia. PROs can be used by individual patients to prioritize the risks and benefits of ESA treatment. Patients, along with their physicians, can examine Hb level in the context of patients' perception of their quality of life and use ESAs judiciously to improve these perceptions.

Outcomes on home haemodialysis: registry challenges

Health care policy is encouraging expansion of home haemodialysis, aiming to improve patient outcomes and reduce cost. However, most patient outcome data derive from retrospective observational studies, with all their inherent weaknesses. Conventional thrice weekly home haemodialysis delivers a 22-51% reduction in mortality, but why should that be? Frequent and/or nocturnal haemodialysis reduces mortality by 36-66%, with comparable outcomes to deceased donor kidney transplantation. Approaches which might improve the quality of future observational studies are discussed. Patient-relevant outcomes other than mortality are also discussed.

The re-emergence of short daily haemodialysis

Thrice weekly in-center hemodialysis is the standard of care for dialysis patients with end-stage renal disease (ESRD). However, there is ongoing debate as to whether more frequent hemodialysis, with its readier management of both toxin and fluid removal, benefits patients. New evidence from recent studies, both in center dialysis and in home haemodialysis patients, adds further confirmation of improved cardiovascular outcome and quality of life in patients undergoing short daily hemodialysis. A paradigm shift in ESRD care delivery may be facilitated due to new technology enabling daily therapy at home.

A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease

Depression is a common, under-recognized, and under-treated problem that is independently associated with increased morbidity and mortality in CKD patients. However, only a minority of CKD patients with depression are treated with antidepressant medications or nonpharmacologic therapy. Reasons for low treatment rates include a lack of properly controlled trials that support or refute efficacy and safety of various treatment regimens in CKD patients. The aim of this manuscript is to provide a comprehensive review of studies exploring depression treatment options in CKD. Observational studies as well as small trials suggest that certain serotonin-selective reuptake inhibitors may be safe to use in patients with advanced CKD and ESRD. These studies were limited by small sample sizes, lack of placebo control, and lack of formal assessment for depression diagnosis. Nonpharmacologic treatments were explored in selected ESRD samples. The most promising data were reported for frequent hemodialysis and cognitive behavioral therapy. Alternative proposed therapies include exercise training regimens, treatment of anxiety, and music therapy. Given the association of depression with cardiovascular events and mortality, and the excessive rates of cardiovascular death in CKD, it becomes imperative to not only investigate whether treatment of depression is efficacious, but also whether it would result in a reduction in morbidity and mortality in this patient population.

Impact of short daily hemodialysis on restless legs symptoms and sleep disturbances

BACKGROUND AND OBJECTIVES

Restless legs syndrome (RLS) and sleep disturbances are common among in-center hemodialysis patients and are associated with increased morbidity/mortality.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The FREEDOM study is an ongoing prospective cohort study investigating the benefits of home short daily hemodialysis (SDHD) (6 times/week). In this interim report, we examine the long-term effect of SDHD on the prevalence and severity of RLS, as measured by the International Restless Legs Syndrome (IRLS) Study Group rating scale, and sleep disturbances, as measured by the Medical Outcomes Study sleep survey.

RESULTS

235 participants were included in this report (intention-to-treat cohort), of which 127 completed the 12-month follow-up (per-protocol cohort). Mean age was 52 years, 55% had an arteriovenous fistula, and 40% suffered from RLS. In the per-protocol analysis, among patients with RLS, the mean IRLS score improved significantly at month 12, after adjustment for use of RLS-related medications (18 versus 11). Among patients with moderate-to-severe RLS (IRLS score ≥15), there was an even greater improvement in the IRLS score (23 versus 13). The intention-to-treat analysis yielded similar results. Over 12 months, there was decline in the percentage of patients reporting RLS (35% versus 26%) and those reporting moderate-to-severe RLS (59% versus 43%). There was a similar and sustained 12-month improvement in several scales of the sleep survey, after adjustment for presence of RLS and use of anxiolytics and hypnotics.

CONCLUSIONS

Home SDHD is associated with long-term improvement in the prevalence and severity of RLS and sleep disturbances.

Home Dialysis in the New USA Bundled Payment Plan: Implications and Impact

On 1 January 2011, a new payment system for Medicare patients will be implemented in the United States. This new system bundles services previously charged separately and under a “fee for service” environment. The authors discuss the implications of this approach. Over the next several pages is a response by American physicians and dialysis innovators to a federal initiative to change the way dialysis is paid for in the United States. Peter Blake, the Editor-in-Chief of Peritoneal Dialysis International, invited Thomas Golper to articulate physicians’ concerns with this new payment scheme. After the government of the USA closed its comment period over the new payment methodology, called “bundling,” Golper sought out colleagues from diverse backgrounds and compiled this collective view of the situation.

Achievements and challenges in bioartificial kidney development

Bioartificial kidneys (BAKs) combine a conventional hemofilter in series with a bioreactor unit containing renal epithelial cells. The epithelial cells derived from the renal tubule should provide transport, metabolic, endocrinologic and immunomodulatory functions. Currently, primary human renal proximal tubule cells are most relevant for clinical applications. However, the use of human primary cells is associated with many obstacles, and the development of alternatives and an unlimited cell source is one of the most urgent challenges. BAKs have been applied in Phase I/II and Phase II clinical trials for the treatment of critically ill patients with acute renal failure. Significant effects on cytokine concentrations and long-term survival were observed. A subsequent Phase IIb clinical trial was discontinued after an interim analysis, and these results showed that further intense research on BAK-based therapies for acute renal failure was required. Development of BAK-based therapies for the treatment of patients suffering from end-stage renal disease is even more challenging, and related problems and research approaches are discussed herein, along with the development of mobile, portable, wearable and implantable devices.

Utilization and outcome of 'out-of-center hemodialysis' in the United States: a contemporary analysis

BACKGROUND

There is increasing interest in the delivery of out-of-center hemodialysis (HD), particularly in the home setting, but little systematic information about its use and outcome in contemporary incident patients is available.

PATIENTS AND METHODS

Out-of-center HD was defined as HD delivered in a residential setting, mainly at home or in a long-term care facility (such as a nursing home) irrespective of the length and frequency of therapy. All-cause mortality was determined in an observational cohort study of 458,329 adult patients initiating dialysis in the United States with Medicare as a primary payer.

RESULTS

Between 1995 and 2004, out-of-center HD was the initial modality in 1,641 (0.4%) of eligible participants, although there was significant geographic variation. Patients initiating out-of-center HD were younger, more likely to be nonwhite, had fewer comorbidities, a higher median income, and were more likely to be employed than patients initiating in-center HD or peritoneal dialysis (PD). In multivariate analysis, out-of-center HD patients had a higher overall risk of death compared to in-center HD or PD patients (HR = 1.10, 95% CI 1.04, 1.17), although the relative risk of death was lower in younger and healthier patients (HR = 0.78; 95% CI 0.61, 1.00).

CONCLUSION

Out-of-center HD is not associated with a survival advantage among unselected patients initiating dialysis in the United States. These results call for better characterization of out-of-center HD in national registries, primarily to effectively compare the use, outcomes and potential benefits of home HD to standard therapies.