Home hemodialysis technique survival: insights and challenges

Clinical implications of serum adropin and clusterin in chronic renal failure patients who received hemodialysis

BACKGROUND

Both Adropin and Clusterin are associated with cardiovascular and cerebrovascular diseases. Unfortunately, the clinical implications of them in Chronic renal failure (CRF) population remains largely unclear.

METHODS

We included 356 CRF patients received hemodialysis. Determination of serum concentrations of Adropin and Clusterin were performed by ELISA.The optimal cutoff values of Adropin or Clusterin for cardiovascular and cerebrovascular complications/death were determined by receiver operating characteristics (ROC) curve analysis. The prognostic value of Adropin and Clusterin was evaluated using Kaplan-Meier survival curves, log-rank tests, and Cox proportional hazards models.

RESULTS

Baseline serum Adropin significantly decreased, while serum Clusterin elevated in CRF patients who suffered cardiovascular or cerebrovascular implications during hemodialysis. Both decreased baseline serum Adropin and increased serum Clusterin showed potentials for predicting cardiovascular/cerebrovascular implications during hemodialysis in CRF patients. Reduced baseline serum Adropin indicated poor prognosis in CRF patient during hemodialysis, whereas increased baseline serum Clusterin indicated poor prognosis in CRF patient during hemodialysis. Combining baseline serum Adropin and Clusterin detection achieved better performance for predicting prognosis in CRF patients.

CONCLUSION

We demonstrated that decreased Adropin, or increased Clusterin could be novel but useful tool for predicting cardiovascular/cerebrovascular complications and overall survival. Importantly, combination of Adropin and Clusterin detection might be help to construct new management system for CRF patients to effectively improve their prognosis in the future.

Home Hemodialysis Practice and Curriculum Recommendations Among Graduates of a Military Nephrology Training Program Without Home Hemodialysis Clinic Experience

INTRODUCTION

The Advancing American Kidney Health Initiative set a goal that ≥80% of new end-stage kidney disease patients receive home dialysis or kidney transplant by 2025. Home hemodialysis (HHD) prevalence remains low, and one barrier may be a lack of familiarity with HHD among nephrologists and insufficient training during fellowship.

MATERIALS AND METHODS

We performed an anonymous survey of 92/94 graduates from the Walter Reed military nephrology program (1984-2023) regarding their HHD practice and training. The home dialysis program includes only peritoneal dialysis, and HHD training is limited to didactics and training with machines used for low-flow dialysate HHD. The survey was conducted from April 12, 2023 to April 2, 2024.

RESULTS

Fifty-two out of ninety-two (57%) responded; 96% completed the survey. Seventy-five percent (38/51) had been in practice for ≤20 years. Forty-three percent (22/51) practice(d) HHD. Of these, 54% (12/22) had been HHD directors/co-directors, and 73% (16/22) had started practice in the last 10 years. The majority were in the southern (50%) or western (23%) United States, and 32% had rural practices. 54% (12/22) followed 6 to 10 patients. Sixty-eight percent reported learning HHD skills "on the job." Barriers most commonly cited were lack of patient interest (41%), lack of patient partners (27%), and lack of nursing staff (27%). Overall, graduates indicated that the minimum effective curriculum for HHD competence should include block/longitudinal HHD clinic (84%), familiarization with HHD machines (82%), didactic lectures (80%), and training in effective counseling (80%).

CONCLUSIONS

Among graduates of a military nephrology training program without HHD clinic experience, 43% reported subsequently practicing HHD, the majority learning "on the job." Overall, graduates indicated that block/longitudinal HHD clinic was the most effective way for fellows to learn HHD skills. Nephrology programs should expect that graduates are likely to care for HHD patients, and prepare them accordingly. In addition, for military nephrologists, HHD skills can be applied to dialysis delivery in austere settings.

Efficacy of slow daily home hemodialysis with internal convection on removal of uremic toxins using the Physidia S3 monitor

Home hemodialysis, despite its recognized clinical benefits such as improved cardiac health and enhanced quality of life, remains underutilized worldwide. This study aims to evaluate the efficacy of home hemodialysis within slow daily dialysis programs, employing the Physidia S3 monitor. A prospective trial was conducted with 16 stable patients suffering from end-stage kidney disease and undergoing home hemodialysis. The study assessed the efficiency of slow daily short treatment dialysis using diverse criteria, including percent reduction, effective clearances, and solute mass removal, across a broad spectrum of uremic compounds, including sodium. Controlled sessions were implemented to replicate daily home treatment conditions. Selecting urea and ß2M as key biomarkers due to their associations with patient outcomes, our study achieved a standardized weekly Kt/V of 2.26 [1.99-2.70] and estimated kidney urea clearance of 11.4 [10.9-12.4] mL/min. ß2M mass removal per session was 146 mg, extrapolating to 707 (×5) and 845 (×6) mg weekly. Additionally, the time-averaged concentration of ß2M was maintained at 19.4 mg/L. The study also identified a net sodium mass removal of 126 mmol [98-182] or 7.4 g [5.8-10.7] NaCl per session. In conclusion, our findings suggest that slow daily, short treatment time, high flux hemodialysis, augmented by enhanced internal convective clearance, represents a highly efficient renal replacement modality on a weekly basis across large molecular weight uremic compounds. Moreover, the solute dialysate saturation coefficient emerges as a promising marker in slow-flow settings.

Home dialysis: there's no place like home

PURPOSE OF REVIEW

The rapid rise in incidence and prevalence of end-stage kidney disease (ESKD) over the past 50 years was matched by a drop-off in use of home dialysis and a proliferation of in-center hemodialysis across the United States. There is renewed interest in improving access to home dialysis modalities for patients with ESKD. The aim of this review is to update kidney care providers with clinical outcome data and new guidelines that promote patient-centered choices, and to address barriers to home dialysis uptake and continued use.

RECENT FINDINGS

Recent literature, including changing practice guidelines for prescribing home dialysis and examining the goals of treatment from the patient and caregiver perspectives will be reviewed. We will examine the impact of newer care models to promote home dialysis for incident ESKD patients. Assisted home dialysis, home dialysis in a nursing home and the impact of new payment models rewarding home dialysis providers will be examined.

SUMMARY

This concise review of recent pertinent literature should give the dialysis provider confidence in advising their patients on the benefits of home dialysis, a glimpse into the future landscape for home dialysis, and hopefully transform kidney care providers into unbiased patient advocates.

The Dual Burden: Exploring Cardiovascular Complications in Chronic Kidney Disease

Chronic kidney disease (CKD) represents a significant global health challenge, affecting millions of individuals and leading to substantial morbidity and mortality. This review aims to explore the epidemiology, cardiovascular complications, and management strategies associated with CKD, emphasizing the importance of preventing cardiovascular disease and early intervention. CKD is primarily driven by conditions such as diabetes mellitus, hypertension, and cardiovascular diseases, which often coexist and exacerbate renal impairment. Effective management requires a multifaceted approach, including lifestyle modifications, pharmacological interventions, and regular monitoring. Dietary changes, such as sodium restriction and a controlled intake of phosphorus and potassium, play a vital role in preserving renal function. Pharmacological therapies, particularly angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and emerging agents like SGLT2 inhibitors, have shown efficacy in slowing disease progression and improving patient outcomes. Furthermore, patients undergoing dialysis face increased cardiovascular risk, necessitating comprehensive management strategies to address both renal and cardiac health. As the landscape of CKD treatment evolves, ongoing research into novel therapeutic options and personalized medical approaches are essential. This review underscores the urgent need for awareness, education, and effective preventive measures to mitigate the burden of CKD and enhance the quality of life for affected individuals.

Vascular Access Considerations in Home Hemodialysis

There is a global interest in expanding home dialysis utilization among patients with ESKD. Home hemodialysis (HHD) is an appealing KRT option for this population because of its multiple clinical and quality of life benefits. Central to successful HHD is the establishment and maintenance of a functioning vascular access that serves as a patient's lifeline while on therapy. While the selection of a vascular access type is influenced by individual patient circumstances, the arteriovenous fistula is generally the preferred access method. Training patients to use their dialysis access requires attention to safety, risk management, and monitoring for complications to minimize adverse events and technique failure. Policies incorporating systematic frameworks for quality improvement and assurance, in conjunction with the measurement of metrics relating to vascular access, are tools that should be used by HHD programs to enhance the value of care delivered. In this perspective, we aim to describe what is currently known about the various vascular access options in HHD and to elucidate what needs to be taken into consideration in the selection and care of this access.

Long-term survival of patients receiving home hemodialysis with self-punctured arteriovenous access

OBJECTIVE

To determine the long-term survival of patients receiving home hemodialysis (HHD) through self-punctured arteriovenous access.

METHODS

We conducted an observational study of all patients receiving HHD at our facility between 2001 and 2020. The primary outcome was treatment survival, and it was defined as the duration from HHD initiation to the first event of death or technique failure. The secondary outcomes were the cumulative incidence of technique failure and mortality. Cox proportional hazard models were used to identify the predictive factors for treatment survival.

RESULTS

A total of 77 patients (mean age, 50.7 years; 84.4% male; 23.4% with diabetes) were included. The median dialysis duration was 18 hours per week, and all patients self-punctured their arteriovenous fistula. During a median follow-up of 116 months, 30 treatment failures (11 deaths and 19 technique failures) were observed. The treatment survival was 100% at 1 year, 83.5% at 5 years, 67.2% at 10 years, and 34.6% at 15 years. Age (adjusted hazard ratio [aHR], 1.07) and diabetes (aHR, 2.45) were significantly associated with treatment survival. Cardiovascular disease was the leading cause of death, and vascular access-related issues were the primary causes of technique failure, which occurred predominantly after 100 months from HHD initiation.

CONCLUSION

This study showed a favorable long-term prognosis of patients receiving HHD. HHD can be a sustainable form of long-term kidney replacement therapy. However, access-related technique failures occur more frequently in patients receiving it over the long term. Therefore, careful management of vascular access is crucial to enhance technique survival.

Pregnancy in Patients Receiving Home Dialysis

Pregnancy is an important goal for many women with CKD or kidney failure, but important barriers exist, particularly as CKD stage progresses. Women with advanced CKD often have a limited fertility window and may miss their opportunity for a pregnancy if advised to defer until after kidney transplantation. Pregnancy rates in women with advanced kidney failure or receiving dialysis remain low, and despite the improved outcomes in recent years, these pregnancies remain high risk for both mother and baby with high rates of preterm birth due to both maternal and fetal complications. However, with increased experience and advances in models of care, this paradigm may be changing. Intensive hemodialysis regimens have been shown to improve both fertility and live birth rates. Increasing dialysis intensity and individualizing dialysis prescription to residual renal function, to achieve highly efficient clearances, has resulted in improved live birth rates, longer gestations, and higher birth weights. Intensive hemodialysis regimens, particularly nocturnal and home-based dialysis, are therefore a potential option for women with kidney failure desiring pregnancy. Global initiatives for the promotion and uptake of home-based dialysis are gaining momentum and may have advantages in this unique patient population. In this article, we review the epidemiology and outcomes of pregnancy in hemodialysis and peritoneal dialysis recipients. We discuss the role home-based therapies may play in helping women achieve more successful pregnancies and outline the principles and practicalities of management of dialysis in pregnancy with a focus on delivery of home modalities. The experience and perspectives of a patient are also shared.