1
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Butt U, Davenport A, Sridharan S, Farrington K, Vilar E. A practical approach to implementing incremental haemodialysis. J Nephrol 2024:10.1007/s40620-024-01939-2. [PMID: 38763995 DOI: 10.1007/s40620-024-01939-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/24/2024] [Indexed: 05/21/2024]
Abstract
The majority of end-stage kidney disease patients are treated with haemodialysis (HD). Starting HD can pose physical, social, and psychological challenges to patients, and mortality rates within the first 6 months are disproportionately high, with intensive HD regimens implicated as a potential factor. Starting HD with an incremental approach, taking residual kidney function (RKF) into account, potentially allows for a gentle start with reduced dialysis intensity. Dialysis intensity (session time or frequency) can then be proportionally increased as RKF reduces. This approach to starting HD has been reported in observational studies to result in better patient self-reported health quality of life and reduced costs, and now several definitive randomised controlled trials are underway comparing an incremental approach to the conventional thrice weekly paradigm. Physician concerns over the risk of inadequate dialysis, with consequent increased emergency admissions, and practical challenges of how to estimate RKF and implement incremental dialysis have impeded widespread adoption. Addressing these challenges is paramount to increasing the uptake of incremental HD. Careful patient selection lies at the heart of a successful incremental HD programme. Generally, patients with a residual urea clearance of > 3 ml/min/1.73 m2 can be considered suitable for starting with incremental HD provided they comply with fluid intake, salt and other dietary recommendations. Calculating RKF from regular interdialytic urine collections and appropriately adjusting sessional HD clearance targets are practical and conceptual challenges. In this report we aim to disentangle these complexities and provide a step-by-step guide for patient selection and adjusting dialysis sessional targets.
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Affiliation(s)
- Usama Butt
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK.
| | - A Davenport
- Royal Free Hospital, Royal Free London Foundation Trust, London, UK
- University College London, London, UK
| | - S Sridharan
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
| | - K Farrington
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
| | - E Vilar
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
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2
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Murea M, Highland BR, Yang W, Dressler E, Russell GB. Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis. BMC Nephrol 2022; 23:322. [PMID: 36167537 PMCID: PMC9513956 DOI: 10.1186/s12882-022-02946-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden. Methods The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group). Results The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD. Conclusions This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations. Trial registration Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02946-w.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - Benjamin R Highland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wesley Yang
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emily Dressler
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
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3
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Jaques DA, Ponte B, Haidar F, Dufey A, Carballo S, De Seigneux S, Saudan P. Outcomes of incident patients treated with incremental haemodialysis as compared with standard haemodialysis and peritoneal dialysis. Nephrol Dial Transplant 2022; 37:2514-2521. [PMID: 35731591 PMCID: PMC9681916 DOI: 10.1093/ndt/gfac205] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Residual kidney function is considered better preserved with incremental haemodialysis (I-HD) or peritoneal dialysis (PD) as compared with conventional thrice-weekly HD (TW-HD) and is associated with improved survival. We aimed to describe outcomes of patients initiating dialysis with I-HD, TW-HD or PD. METHODS We conducted a retrospective analysis of a prospectively assembled cohort in a single university centre including all adults initiating dialysis from January 2013 to December 2020. Primary and secondary endpoints were overall survival and hospitalization days at 1 year, respectively. RESULTS We included 313 patients with 234 starting on HD (166 TW-HD and 68 I-HD) and 79 on PD. At the end of the study, 10 were still on I-HD while 45 transitioned to TW-HD after a mean duration of 9.8 ± 9.1 months. Patients who stayed on I-HD were less frequently diabetics (P = .007). Mean follow-up was 33.1 ± 30.8 months during which 124 (39.6%) patients died. Compared with patients on TW-HD, those on I-HD had improved survival (hazard ratio 0.49, 95% confidence interval 0.26-0.93, P = .029), while those on PD had similar survival. Initial kidney replacement therapy modality was not significantly associated with hospitalization days at 1 year. CONCLUSIONS I-HD is suitable for selected patients starting dialysis and can be maintained for a significant amount of time before transition to TW-HD, with diabetes being a risk factor. Although hospitalization days at 1 year are similar, initiation with I-HD is associated with improved survival as compared with TW-HD or PD. Results of randomized controlled trials are awaited prior to large-scale implementation of I-HD programmes.
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Affiliation(s)
| | - Belen Ponte
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Fadi Haidar
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Anne Dufey
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Sebastian Carballo
- Division of Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sophie De Seigneux
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Patrick Saudan
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
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4
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Hazara AM, Allgar V, Twiddy M, Bhandari S. A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol. Clin Exp Nephrol 2021; 25:1131-1141. [PMID: 34101030 PMCID: PMC8421284 DOI: 10.1007/s10157-021-02072-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/26/2021] [Indexed: 12/12/2022]
Abstract
Background Incremental haemodialysis/haemodiafiltration (HD) may help reduce early mortality rates in patients starting HD. This mixed-method feasibility study aims to test the acceptability, tolerance and safety of a novel incremental HD regime, and to study its impact on parameters of patient wellbeing.
Method We aim to enrol 20 patients who will commence HD twice-weekly with progressive increases in duration and frequency, achieving conventional treatment times over 15 weeks (incremental group). Participants will be followed-up for 6 months and will undergo regular tests including urine collections, bio-impedance analyses and quality-of-life questionnaires. Semi-structured interviews will be conducted to explore patients’ prior expectations from HD, their motivations for participation and experiences of receiving incremental HD. For comparison of safety and indicators of dialysis adequacy, a cohort of 40 matched patients who previously received conventional HD will be constructed from local dialysis records (historical controls).
Results Data will be recorded on the numbers screened and proportions consented and completing the study (primary outcome). Incremental and conventional groups will be compared in terms of differences in blood pressure control, interdialytic weight changes, indicators of dialysis adequacy and differences in adverse and serious adverse events. In analyses restricted to incremental group, measurements of RRF, fluid load and quality-of-life during follow-up will be compared with baseline values. From patient interviews, a narrative description of key themes along with anonymised quotes will be presented. Conclusion Results from this study will address a significant knowledge gap in the prescription HD therapy and inform the development novel future therapy regimens.
Supplementary Information The online version contains supplementary material available at 10.1007/s10157-021-02072-1.
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Affiliation(s)
- Adil M Hazara
- Hull York Medical School, Hull, UK. .,Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, UK.
| | - Victoria Allgar
- Peninsula Medical School, Faculty of Health, University of Plymouth, N15, ITTC Building 1, Plymouth Science Park, Plymouth, PL6 8BX, UK
| | - Maureen Twiddy
- Institute of Clinical and Applied Health Research, University of Hull, Hull, HU6 7RX, UK
| | - Sunil Bhandari
- Hull York Medical School, Hull, UK.,Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, UK
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5
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Casino FG, Deira J, Suárez MA, Aguilar J, Basile C. Routine assessment of kidney urea clearance, dialysis dose and protein catabolic rate in the once-weekly haemodialysis regimen. J Nephrol 2021; 34:2009-2015. [PMID: 33891294 DOI: 10.1007/s40620-021-01033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/16/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The dialysis dose (Kt/V) and normalized protein catabolic rate (PCRn) are the most useful indices derived from the urea kinetic model (UKM) in haemodialysis (HD) patients. The kidney urea clearance (Kru) is another important UKM parameter which plays a key role in the prescription of incremental HD. Ideally, the three kinetic parameters should be assessed using the complex software Solute Solver based on the double pool UKM. In the clinical setting, however, the three indices are estimated with simplified formulae. The recently introduced software SPEEDY assembles the aforementioned equations in a plain spreadsheet, to produce quite accurate results of Kru, Kt/V and PCRn. Unfortunately, specific equations to compute Kt/V and PCRn for patients on a once-weekly HD regimen (1HD/wk) were not available at the time SPEEDY was built-up. We devised a new version of SPEEDY (SPEEDY-1) and an even simpler variant (SPEEDY-1S), using two recently published equations for the 1HD/wk schedule . Moreover, we also added a published equation to estimate the equivalent renal clearance (EKR) normalized to urea distribution volume (V) of 35 L (EKR35) from Kru and Kt/V . Aim of the present study was to compare the results obtained using the new methods (SPEEDY-1 and SPEEDY-1S) with those provided by the reference method Solute Solver. SUBJECTS AND METHODS One hundred historical patients being treated with the once-weekly HD regimen were enrolled. A total of 500 HD sessions associated to the availability of monthly UKM studies were analysed in order to obtain Kru, single pool Kt/V (spKt/V), equilibrated Kt/V (eKt/V), V, PCRn and EKR35 values by using Solute Solver, SPEEDY-1 and SPEEDY-1S. RESULTS When comparing the paired values of the above UKM parameters, as computed by SPEEDY-1 and Solute Solver, respectively, all differences but one were statistically significant at the one-sample t-test; however, the agreement limits at Bland-Altman analysis showed that all differences were negligible. When comparing the paired values of the above UKM parameters, as computed by SPEEDY-1S and Solute Solver, respectively, all differences were statistically significant; however, the agreement limits showed that the differences were negligible as far as Kru, spKt/V and eKt/V are concerned, though much larger regarding V, PCRn and EKR35. CONCLUSIONS We implemented SPEEDY with a new version specific for the once-weekly HD regimen, SPEEDY-1. It provides accurate results and is presently the best alternative to Solute Solver. Using SPEEDY-1S led to a larger difference in PCRn and EKR35, which could be acceptable for clinical practice if SPEEDY-1 is not available.
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Affiliation(s)
- Francesco Gaetano Casino
- Dialysis Centre SM2, Policoro, Italy
- Division of Nephrology, Miulli General Hospital, 70021, Acquaviva delle Fonti, Italy
| | - Javier Deira
- Division of Nephrology, San Pedro de Alcantara Hospital, Cáceres, Spain
| | - Miguel A Suárez
- Division of Nephrology, Virgen del Puerto Hospital, Cáceres, Spain
| | - José Aguilar
- Division of Nephrology, San Pedro de Alcantara Hospital, Cáceres, Spain
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, 70021, Acquaviva delle Fonti, Italy.
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
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6
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Bolasco P, Casula L, Contu R, Cadeddu M, Murtas S. Evaluation of Residual Kidney Function during Once-Weekly Incremental Hemodialysis. Blood Purif 2020; 50:246-253. [PMID: 33080618 DOI: 10.1159/000509790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The initial once-weekly administration of incremental hemodialysis to patients with residual kidney function (RKF) has recently attracted considerable interest. METHODS The aim of our study was to assess the performance of a series of different methods in measuring serum urea nitrogen and serum Cr (sCr) RKF in patients on once-weekly hemodialysis (1WHD). Evaluations were carried out by means of 24-h predialysis urine collection (Kr-24H) or 6-day inter-dialysis collection (Kr-IDI) and estimation of glomerular filtration rate based on (KrSUN + KrsCr)/2 for the purpose of identifying a simple reference calculation to be used in assessing RKF in patients on 1WHD dialysis. Ninety-five urine samples were collected from 12 1WHD patients. A solute solver urea and Cr kinetic modeling program was used to calculate residual urea and Cr clearances. Mann-Whitney U test, Pearson's correlation coefficient (R), and linear determination coefficient (R2) were used for statistical analysis. RESULTS 1WHD patients displayed a mean KrSUN-IDI of 4.5 ± 1.2 mL/min, while KrSUN-24H corresponded to 4.1 ± 0.9 mL/min, mean KrsCr-IDI to 9.1 ± 4.0 mL/min, and KrsCr 24H to 8.9 ± 4.2 mL/min, with a high regression between IDI and 24-h clearances (for IDI had R2 = 0.9149 and for 24H had R2 = 0.9595). A good correlation was also observed between KrSUN-24H and (KrSUN + KrsCR/2) (R2 = 0.7466, p < 0.01. DISCUSSION Urine collection over a 24-h predialysis period yielded similar results for both KrSUN and KrsCr compared to collection over a longer interdialytic interval (KrSUN + KrsCr)/2 could be applied to reliably assess RKF in patients on 1WHD. CONCLUSION The parameters evaluated are suitable for use as a routine daily method indicating the commencement and continued use of the 1WHD Incremental Program.
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Affiliation(s)
- Piergiorgio Bolasco
- Treatment Study Group of Chronic Renal Disease of Italian Society of Nephrology, Italy Official Nephrologist Consultant of Regional Health Institution of Sardinia, Cagliari, Italy,
| | - Laura Casula
- Department of Public Health, Clinical and Molecular Medicine-University of Cagliari, Cagliari, Italy
| | - Rita Contu
- Department of Hemodialysis, ASSL di Cagliari, Cagliari, Italy
| | | | - Stefano Murtas
- Department of Hemodialysis, ASSL di Cagliari, Cagliari, Italy
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7
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Kaja Kamal RM, Farrington K, Busby AD, Wellsted D, Chandna H, Mawer LJ, Sridharan S, Vilar E. Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function. Nephrol Dial Transplant 2020; 34:1017-1025. [PMID: 30357360 DOI: 10.1093/ndt/gfy321] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters. METHODS We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD). RESULTS The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight. CONCLUSION 2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.
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Affiliation(s)
- Raja Mohammed Kaja Kamal
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Amanda D Busby
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - David Wellsted
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Humza Chandna
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Laura J Mawer
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Sivakumar Sridharan
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Enric Vilar
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
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8
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Lee YJ, Okuda Y, Sy J, Obi Y, Kang DH, Nguyen S, Hsiung JT, Park C, Rhee CM, Kovesdy CP, Streja E, Kalantar-Zadeh K. Association of Mineral Bone Disorder With Decline in Residual Kidney Function in Incident Hemodialysis Patients. J Bone Miner Res 2020; 35:317-325. [PMID: 31610040 DOI: 10.1002/jbmr.3893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/15/2019] [Accepted: 09/11/2019] [Indexed: 01/17/2023]
Abstract
Abnormalities of mineral bone disorder (MBD) parameters have been suggested to be associated with poor renal outcome in predialysis patients. However, the impact of those parameters on decline in residual kidney function (RKF) is uncertain among incident hemodialysis (HD) patients. We performed a retrospective cohort study in 13,772 patients who initiated conventional HD during 2007 to 2011 and survived 6 months of dialysis. We examined the association of baseline serum phosphorus, calcium, intact parathyroid hormone (PTH), and alkaline phosphatase (ALP) with a decline in RKF. Decline in RKF was assessed by estimated slope of renal urea clearance (KRU) over 6 months from HD initiation. Our cohort had a mean ± SD age of 62 ± 15 years; 64% were men, 57% were white, 65% had diabetes, and 51% had hypertension. The median (interquartile range [IQR]) baseline KRU level was 3.4 (2.0, 5.2) mL/min/1.73 m2 . The median (IQR) estimated 6-month KRU slope was -1.47 (-2.24, -0.63) mL/min/1.73 m2 per 6 months. In linear regression models, higher phosphorus categories were associated with a steeper 6-month KRU slope compared with the reference category (phosphorus 4.0 to <4.5 mg/dL). Lower calcium and higher intact PTH and ALP categories were also associated with a steeper 6-month KRU slope compared with their respective reference groups (calcium 9.2 to <9.5 mg/dL; intact PTH 150 to <250 pg/mL; ALP <60 U/L). The increased number of parameter abnormalities had an additive effect on decline in RKF. Abnormalities of MBD parameters including higher phosphorus, intact PTH, ALP and lower calcium levels were independently associated with decline in RKF in incident HD patients. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Yu-Ji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Yusuke Okuda
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - John Sy
- Nephrology Section, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Duk-Hee Kang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Division of Nephrology, Department of Internal Medicine, Ewha Womans University College of Medicine, Ewha Medical Research Center, Seoul, Korea
| | - Steven Nguyen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jui Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
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9
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Hanna RM, Kalantar-Zadeh K. Estimating Residual Kidney Function With and Without Urine Clearance Measures: A Useful Tool for Incremental Dosing of Dialysis. Kidney Med 2019; 1:332-334. [PMID: 33015607 PMCID: PMC7525141 DOI: 10.1016/j.xkme.2019.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Ramy M. Hanna
- Division of Nephrology and Hypertension and Kidney Transplantation, and Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension and Kidney Transplantation, and Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
- Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, CA
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10
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Deira J, Suárez MA, López F, García-Cabrera E, Gascón A, Torregrosa E, García GE, Huertas J, de la Flor JC, Puello S, Gómez-Raja J, Grande J, Lerma JL, Corradino C, Musso C, Ramos M, Martín J, Basile C, Casino FG. IHDIP: a controlled randomized trial to assess the security and effectiveness of the incremental hemodialysis in incident patients. BMC Nephrol 2019; 20:8. [PMID: 30626347 PMCID: PMC6325813 DOI: 10.1186/s12882-018-1189-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 12/17/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Most people who make the transition to renal replacement therapy (RRT) are treated with a fixed dose thrice-weekly hemodialysis réegimen, without considering their residual kidney function (RKF). Recent papers inform us that incremental hemodialysis is associated with preservation of RKF, whenever compared with conventional hemodialysis. The objective of the present controlled randomized trial (RCT) is to determine if start HD with one sessions per week (1-Wk/HD), it is associated with better patient survival and other safety parameters. METHODS/DESIGN IHDIP is a multicenter RCT experimental open trial. It is randomized in a 1:1 ratio and controlled through usual clinical practice, with a low intervention level and non-commercial. It includes 152 incident patients older than 18 years, with a RRF of ≥4 ml/min/1.73 m2, measured by renal clearance of urea (KrU). The intervention group includes 76 patients who will start with incremental HD (1-Wk/HD). The control group includes 76 patients who will start with thrice-weekly hemodialysis régimen. The primary outcome is assessing the survival rate, while the secondary outcomes are the morbidity rate, the clinical parameters, the quality of life and the efficiency. DISCUSSION This study will enable to know the number of sessions a patient should receive when starting HD, depending on his RRF. The potentially important clinical and financial implications of incremental hemodialysis warrant this RCT. TRIAL REGISTRATION U.S. National Institutes of Health, ClinicalTrials.gov . Number: NCT03239808 , completed 13/04/2017. SPONSOR Foundation for Training and Research of Health Professionals of Extremadura.
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Affiliation(s)
- Javier Deira
- Hospital San Pedro de Alcantara, Cáceres, Spain.
| | | | | | | | | | | | | | - Jorge Huertas
- Hospital de Especialidades de las Fuerzas Armadas, Quito, Ecuador
| | | | - Suleya Puello
- Hospital Clínico Universitario, Santiago de Compostela, Spain
| | | | | | - José L Lerma
- Complejo Asistencial Universitario, Salamanca, Spain
| | | | - Carlos Musso
- Hospital Durand de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Bari, Italy.,Dialysis Centre SM2, Potenza, Italy
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Hur I, Lee Y, Kalantar-Zadeh K, Obi Y. Individualized Hemodialysis Treatment: A Perspective on Residual Kidney Function and Precision Medicine in Nephrology. Cardiorenal Med 2018; 9:69-82. [DOI: 10.1159/000494808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/20/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Residual kidney function (RKF) is often expected to inevitably and rapidly decline among hemodialysis patients and, hence, has been inadvertently ignored in clinical practice. The importance of RKF has been revisited in some recent studies. Given that patients with end-stage renal disease now tend to initiate maintenance hemodialysis therapy with higher RKF levels, there seem to be important opportunities for incremental hemodialysis by individualizing the dose and frequency according to their RKF levels. This approach is realigned with precision medicine and patient-centeredness. Summary: In this article, we first review the available methods to estimate RKF among hemodialysis patients. We then discuss the importance of maintaining and monitoring RKF levels based on a variety of clinical aspects, including volume overload, blood pressure control, mineral and bone metabolism, nutrition, and patient survival. We also review several potential measures to protect RKF: the use of high-flux and biocompatible membranes, the use of ultrapure dialysate, the incorporation of hemodiafiltration, incremental hemodialysis, and a low-protein diet, as well as general care such as avoiding nephrotoxic events, maintaining appropriate blood pressure, and better control of mineral and bone disorder parameters. Key Message: Individualized hemodialysis regimens may maintain RKF, lead to a better quality of life without compromising long-term survival, and ensure precision medicine and patient-centeredness in nephrology practice.
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12
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Casino FG, Basile C. A user-friendly tool for incremental haemodialysis prescription. Nephrol Dial Transplant 2018; 33:1046-1053. [DOI: 10.1093/ndt/gfx343] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 10/29/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Francesco Gaetano Casino
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy
- Dialysis Centre SM2, Potenza, Italy
| | - Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy
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13
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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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Kalantar-Zadeh K, Crowley ST, Beddhu S, Chen JLT, Daugirdas JT, Goldfarb DS, Jin A, Kovesdy CP, Leehey DJ, Moradi H, Navaneethan SD, Norris KC, Obi Y, O’Hare A, Shafi T, Streja E, Unruh ML, Vachharajani T, Weisbord S, Rhee CM. Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease. Semin Dial 2017; 30:251-261. [PMID: 28421638 PMCID: PMC5418081 DOI: 10.1111/sdi.12601] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, the receipt of care within the VA system is associated with favorable outcomes, potentially because of the enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center "Transition-of-Care-in-CKD" suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared with the non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen might preserve RKF, prolong vascular access longevity, improve patients' quality of life, and be a more patient-centered approach, more consistent with "personalized" dialysis. Broad implementation of incremental dialysis might also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are needed to examine the safety and efficacy of incremental hemodialysis in Veterans and other populations; the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, California
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Susan T. Crowley
- VHA National Program Director for Kidney Disease; and Renal Section, VA Connecticut Healthcare System, and Yale University, New Haven, Connecticut
| | - Srinivasan Beddhu
- University of Utah Health Sciences Center, and VA Salt Lake City, Salt Lake City, Utah
| | - Joline LT Chen
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | | | | | - Anna Jin
- VA Long Beach Healthcare System, Long Beach, California
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Hamid Moradi
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Sankar D Navaneethan
- Michael E. Debakey VA Medical center and Baylor College of Medicine, Houston, Texas
| | - Keith C Norris
- Department of Medicine, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Yoshitsugu Obi
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Ann O’Hare
- Puget Sounds VA Healthcare System, and University of Washington Seattle, Washington
| | - Tariq Shafi
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elani Streja
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, California
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Mark L. Unruh
- New Mexico VA Health Care System, and University of New Mexico; Albuquerque, New Mexico
| | - Tushar Vachharajani
- W. G. (Bill) Hefner VA Medical Center, and Edwards Via College of Osteopathic Medicine, Salisbury, North Carolina
| | - Steven Weisbord
- VA Pittsburgh Healthcare System; and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Connie M. Rhee
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, California
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