Incremental and twice weekly haemodialysis in Australia and New Zealand

Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial)

BACKGROUND

Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients.

METHODS

An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients).

DISCUSSION

Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

Incremental versus conventional haemodialysis in end-stage kidney disease: a systematic review and meta-analysis

Background

Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice-weekly haemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD compared with conventional HD were explored in this systematic review and meta-analysis.

Methods

We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization and mortality.

Results

A total of 36 articles (138 939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD {odds ratio [OR] 0.87 [95% confidence interval (CI)] 0.72-1.04 and OR 0.67 [95% CI 0.43-1.05], respectively}. However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD [OR 0.44 (95% CI 0.27-0.72) and OR 0.31 (95% CI 0.25-0.39), respectively]. In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events [OR 0.22 (95% CI 0.08-0.63)] and mortality [OR 0.54 (95% CI 0.37-0.79)]. Vascular access complications, hyperkalaemia and volume overload were not statistically different between groups.

Conclusions

Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.

Australian Workshops on Patients' Perspectives on Hemodialysis and Incremental Start

Introduction

Most patients with kidney failure commence and continue hemodialysis (HD) thrice weekly. Incremental initiation (defined as HD less than thrice weekly) is increasingly considered to be safe and less burdensome, but little is known about patients' perspectives. We aimed to describe patients' priorities and concerns regarding incremental HD.

Methods

Patients currently, previously, or soon to be receiving HD in Australia participated in two 90-minute online workshops to discuss views about HD focusing on incremental start and priorities for trial outcomes. Transcripts were analyzed using thematic analysis. Outcomes were ranked on the basis of the sum of participants' priority scores (i.e., single allocation of 3 points for most important, 2 for second, and 1 for third most important outcome).

Results

All 26 participants (1 caregiver and 25 patients) preferred an incremental HD approach. The top prioritized outcomes were quality of life (QOL) (56 points), residual kidney function (RKF) (27 points), and mortality (16 points). The following 4 themes underpinning outcome priorities, experience, and safety concerns were identified: (i) unpreparedness and pressure to adapt, (ii) disruption to daily living, (iii) threats to safety, and (iv) hope and future planning.

Conclusion

Patients with kidney failure preferred an incremental start to HD to minimize disruption to daily living and reduce the negative impacts on their education, ability to work, and family life. QOL was the most critically important outcome, followed by RKF and survival.

Impact of incremental initiation of haemodialysis on mortality: a systematic review and meta-analysis

BACKGROUND

Incremental haemodialysis initiation entails lower sessional duration and/or frequency than the standard 4 h thrice-weekly approach. Dialysis dose is increased as residual kidney function (RKF) declines. This systematic review evaluates its safety, efficacy and cost-effectiveness.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases from inception to 27 February 2022. Eligible studies compared incremental haemodialysis (sessions either fewer than three times weekly or of duration <3.5 h) with standard treatment. The primary outcome was mortality. Secondary outcomes included treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness. The study protocol was prospectively registered. Risk of bias assessment used the Newcastle-Ottawa Scale and the revised Cochrane risk of bias tool, as appropriate. Meta-analyses were undertaken in Review Manager, Version 5.4.

RESULTS

A total of 644 records were identified. Twenty-six met the inclusion criteria, including 22 cohort studies and two randomized controlled trials (RCTs). Sample size ranged from 48 to 50 596 participants (total 101 476). We found no mortality differences (hazard ratio = 0.99; 95% CI 0.80-1.24). Cohort studies suggested similar hospitalization rates though the two small RCTs suggested less hospitalization after incremental initiation (relative risk = 0.31; 95% CI 0.18-0.54). Data on other treatment-emergent adverse events and quality of life was limited. Observational studies suggested reduced loss of RKF in incremental haemodialysis. This was not supported by RCT data. Four studies reported reduced costs of incremental treatments.

CONCLUSIONS

Incremental initiation of haemodialysis does not confer greater risk of mortality compared with standard treatment. Hospitalization may be reduced and costs are lower.

Twice versus thrice weekly hemodialysis: A systematic review

INTRODUCTION

Thrice weekly hemodialysis (HD) is currently the norm in high income countries but there is mounting interest in twice weekly HD in certain settings. We performed this systematic review to summarize the available evidence comparing twice to thrice weekly HD.

METHODS

A systematic literature search was performed in Ovid MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify cohort and randomized controlled trials evaluating outcomes of twice versus thrice weekly HD. The bibliographies of identified studies were hand searched to find any additional studies. Risk of bias was assessed using the Newcastle-Ottawa scale for observational studies.

FINDINGS

No randomized controlled trials and 21 cohort studies were identified. Overall study quality was modest with high risk of selection bias and inadequate controlling for confounders. The most commonly evaluated outcome measures were survival and residual kidney function. No studies assessed quality of life. Study results were variable and there was no clear signal for overwhelming risk or benefit of twice versus thrice weekly HD with the exception of residual kidney function which consistently showed slower decline in the twice weekly group.

DISCUSSION

There is a paucity of high quality data comparing the risks and benefits of twice vs thrice weekly HD. Randomized controlled trial evidence is required to inform clinicians and HD prescription guidelines.

Incremental and Personalized Hemodialysis Start: A New Standard of Care

Introduction

Incremental hemodialysis (iHD) may attenuate “dialysis shock” and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards’ routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start.

Methods

This observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1–2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015–2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry.

Results

A total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m², P = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests.

Conclusion

Our study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD.

A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol

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.

Individualized acute kidney injury after care

PURPOSE OF REVIEW

The aim of this study was to summarize the current evidence around the impact of individualizing patient care following an episode of acute kidney injury (AKI) in the ICU.

RECENT FINDINGS

Over the last years, evidence has demonstrated that the follow-up care after episodes of AKI is lacking and standardization of this process is likely needed. Although this is informed largely by large retrospective cohort studies, a few prospective observational trials have been performed. Medication reconciliation and patient/caregiver education are important tenants of follow-up care, regardless of the severity of AKI. There is evidence the initiation and/or reinstitution of renin-angiotensin-aldosterone agents may improve patient's outcomes following AKI, although they may increase the risk for adverse events, especially when reinitiated early. In addition, 3 months after an episode of AKI, serum creatinine and proteinuria evaluation may help identify patients who are likely to develop progressive chronic kidney disease over the ensuing 5 years. Lastly, there are emerging differences between those who do and do not require renal replacement therapy (RRT) for their AKI, which may require more frequent and intense follow-up in those needing RRT.

SUMMARY

Although large scale evidence-based guidelines are lacking, standardization of post-ICU-AKI is needed.

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.