Nocturnal hemodialysis: three-year experience

Home Dialysis in North America: The Current State

There is widespread interest in expanding the uptake of home dialysis in North America. Although kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for KRT. In this review, the motivation for promoting home dialysis is presented, and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD with in-center HD have been challenging to conduct and provide only limited information. Nonrandomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias, and this must be carefully considered when evaluating this literature. Home modalities seem to have equivalent clinical outcomes and quality of life when compared with in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted, and a framework for proposing targets is presented, using PD as an example.

Analytical solution of phosphate kinetics for hemodialysis

Chronic kidney diseases imply an ongoing need to remove toxins, with hemodialysis as the preferred treatment modality. We derive analytical expressions for phosphate clearance during dialysis, the single pass (SP) model corresponding to a standard clinical hemodialysis and the multi pass (MP) model, where dialysate is recycled and therefore makes a smaller clinical setting possible such as a transportable dialysis suitcase. For both cases we show that the convective contribution to the dialysate is negligible for the phosphate kinetics and derive simpler expressions. The SP and MP models are calibrated to clinical data of ten patients showing consistency between the models and provide estimates of the kinetic parameters. Immediately after dialysis a rebound effect is observed. We derive a simple formula describing this effect which is valid both posterior to SP or MP dialysis. The analytical formulas provide explanations to observations of previous clinical studies.

Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021

People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.

Health-Related Quality of Life in End-Stage Renal Disease Patients and Healthy Individuals

Background:

Health-related quality of life (HRQOL) is an important outcome measure in patients with end-stage renal disease (ESRD). HRQOL is assumed to improve with kidney transplantation and compared to hemodialysis. However, there is no evidence regarding HRQOL to support the optimal treatment choice for patients on hemodialysis who hesitate opting for transplantation. Therefore, this study aims to compare HRQOL between patients with ESRD and healthy individuals.

Materials and Methods:

This case-control study was performed of 50 patients with ESRD under hemodialysis and 100 healthy participants as controls. HRQOL was assess using the SF-36 questionnaire. Data was analysis by using linear regression to compared HRQOL between groups, and adjusted for age, gender, dialysis duration.

Results:

Most of the patients were males (62%) and aged 21 to 60 years old (82%). The patients and healthy subjects were significantly different in terms of the presence of chronic diseases (P<0.05). ESRD patients had a significantly lower level of satisfaction with health and function, family and friends, and social and psychological functions. The patients’ quality of life was not significantly affected by their demographic characteristics, including age, gender, educational level, marital status, and financial status. However, there was a significant association between chronic disease and HRQOL among ESRD (P=0.0001).

Conclusion:

ESRD has a remarkably negative effect on the patients’ quality of life and satisfaction with important domains of life. HRQOL among patients with end-stage renal disease can be affected by the associated chronic diseases.

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.

Nocturnal Hemodialysis: Why Aren't More People Doing It?

Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.

Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.

Progression of coronary artery calcification in conventional hemodialysis, nocturnal hemodialysis, and kidney transplantation

Introduction

Cardiovascular disease is the leading cause of death in end-stage renal disease (ESRD) and is strongly associated with vascular calcification. An important driver of vascular calcification is high phosphate levels, but these become lower when patients initiate nocturnal hemodialysis or receive a kidney transplant. However, it is unknown whether nocturnal hemodialysis or kidney transplantation mitigate vascular calcification. Therefore, we compared progression of coronary artery calcification (CAC) between patients treated with conventional hemodialysis, nocturnal hemodialysis, and kidney transplant recipients.

Methods

We measured CAC annually up to 3 years in 114 patients with ESRD that were transplantation candidates: 32 that continued conventional hemodialysis, 34 that initiated nocturnal hemodialysis (≥4x 8 hours/week), and 48 that received a kidney transplant. We compared CAC progression between groups as the difference in square root transformed volume scores per year (ΔCAC SQRV) using linear mixed models. Reference category was conventional hemodialysis.

Results

The mean age of the study population was 53 ±13 years, 75 (66%) were male, and median dialysis duration was 28 (IQR 12–56) months. Median CAC score at enrollment was 171 (IQR 10–647), which did not differ significantly between treatment groups (P = 0.83). Compared to conventional hemodialysis, CAC progression was non-significantly different in nocturnal hemodialysis -0.10 (95% CI -0.77 to 0.57) and kidney transplantation -0.33 (95% CI -0.96 to 0.29) in adjusted models.

Conclusions

Nocturnal hemodialysis and kidney transplantation are not associated with significantly less CAC progression compared to conventional hemodialysis during up to 3 years follow-up. Further studies are needed to confirm these findings, to determine which type of calcification is measured with CAC in end-stage renal disease, and whether that reflects cardiovascular risk.

Technique Survival and Determinants of Technique Failure in In-Center Nocturnal Hemodialysis: A Retrospective Observational Study

Background

Long-duration (7-8 hours) hemodialysis provides benefits compared with conventional thrice-weekly, 4-hour sessions. Nurse-administered, in-center nocturnal hemodialysis (INHD) may expand the population to whom an intensive dialysis schedule can be offered.

Objective

The primary objective of this study was to determine predictors of INHD technique failure, disruptions, and technique survival.

Design

This study used retrospective chart and database review methodology.

Setting

This study was conducted at a single Canadian INHD program operating in Victoria, British Columbia, within a tertiary care hospital. Our program serves a catchment population of approximately 450 000 people.

Patients/Sample/Participants

Forty-three consecutive incident INHD patients took part in the INHD program of whom 42 provided informed consent to participate in this study.

Methods

We conducted a retrospective observational study including incident INHD patients from 2015 to 2017. The primary outcome was technique failure ≤6 months (TF ≤6). Secondary outcomes included technique survival and reasons for/predictors of INHD discontinuation or temporary disruption. Predictors of each outcome included demographics, comorbidities, and Clinical Frailty Scale (CFS) scoring.

Results

Among 42 patients, mean (SD) age, dialysis vintage, CFS score, and follow-up were 63 (16) years, 46 (55) months, 4 (1), and 11 (9) months, respectively. 52% were aged ≥65 years. TF ≤6 occurred in 12 (29%) patients. One-year technique survival censored for transplants and home dialysis transitions was 60%. Discontinuation related to insomnia (32%), medical status change (27%), and vascular access (23%). In unadjusted Cox survival analysis, 1-point increases in CFS score associated with a higher risk of technique failure (hazard ratio: 2.04, 95% confidence interval [CI]: 1.26-3.31). In an adjusted analysis, higher frailty severity also associated with temporary INHD disruptions (incidence rate ratio: 2.64, 95% CI: 1.55-4.50, comparing CFS of ≥4 to 1-3).

Limitations

The retrospective, observational design of this study resulted in limited ability to control for confounding factors. In addition, the relatively small number of events observed owing to a small sample size diminished statistical power to inform study conclusions. Use of a single physician to determine the clinical frailty score is another limitation. Finally, the use of a single center for this study limits generalizability to other programs and clinic settings.

Conclusions

INHD is a sustainable modality, even among older patients. Higher frailty associates with INHD technique failure and greater missed treatments. Inclusion of a CFS threshold of ≤4 into INHD inclusion criteria may help to identify individuals most likely to realize the long-term benefits of INHD.

Trial Registration

Due to the retrospective and observational design of this study, trial registration was not necessary.

Nocturnal hemodialysis: improved quality of life and patient outcomes

Conventional hemodialysis is associated with high morbidity and mortality rates, as well as a reduced quality of life. There is a growing interest in the provision of more intensive hemodialysis, due to associated benefits in terms of reduced cardiovascular morbidity, better regulation of mineral metabolism, as well as its impact on quality of life measures, fertility, and sleep. Nocturnal hemodialysis, both in center and at home, allows the delivery of more intensive hemodialysis. This review discusses the benefits of nocturnal hemodialysis and evaluates the evidence based on available literature.

Current approaches to middle molecule removal: room for innovation

Aggressive removal of middle molecules or larger low-molecular-weight proteins (LMWPs) has been a growing concern following studies on their harmful effects on the mortality and morbidity of chronic dialysis patients. To remove larger LMWPs and some protein-bound uremic toxins (PBUTs), high- and medium-cutoff (HCOs and MCOs, respectively) membranes, convective therapy and protein adsorptive membranes are available. When we use HCO or MCO membranes for convective therapy, we have to take care to avoid massive albumin leakage during a dialysis session. Convection volume is an important element to increase middle molecule removal; however, a larger convection volume has a risk of larger leakage of albumin. Predilution hemodiafiltration is a useful measurement to increase larger LMWPs without massive albumin leakage. β2-microglobulin (B2M), α1-microglobulin (A1M) and albumin leakage during a dialysis session are useful parameters for assessing middle-molecule removal. Reduction ratios of B2M >80% and of A1M >35% are favorable to improve severe dialysis-related symptoms. The efficacy of middle molecule removal should be evaluated in comparison with clinical outcomes, mortality, morbidity and the improvement of dialysis-related symptoms. Recently some dialysis-related symptoms such as sleep disturbance, skin itchiness and dialysis hypotension have been recognized as good surrogate makers for mortality. Further studies to evaluate the relationship between middle molecule or PBUTs removal and the improvement of patient symptoms should be performed in well-designed randomized controlled trials.

Health-related quality of life compared between kidney transplantation and nocturnal hemodialysis

Background

Health-related quality of life (HRQOL) is an important outcome measure in patients with end-stage renal disease. HRQOL is assumed to improve with kidney transplantation and also with nocturnal hemodialysis compared to conventional hemodialysis. However, there is no evidence regarding HRQOL to support the optimal treatment choice for patients on nocturnal hemodialysis who hesitate opting for transplantation. We therefore compared HRQOL between patients who were treated with kidney transplantation or nocturnal hemodialysis for one year.

Methods

We assessed HQROL using the Kidney Disease Quality of Life–Short Form questionnaire in a cross-sectional sample of patients who were treated with kidney transplantation (n = 41) or nocturnal hemodialysis (n = 31) for one year. All patients on nocturnal hemodialysis were transplantation candidates. Using linear regression, we compared HRQOL between kidney transplantation and nocturnal hemodialysis, and adjusted for age, sex, dialysis duration, cardiovascular disease, and presence of residual urine production.

Results

At one year follow-up, mean age of the study population was 54 ±13 years, and median dialysis duration was 3.2 (IQR 2.1–5.0) years. Kidney transplantation was associated with significantly higher HRQOL on the domain “effects” compared to nocturnal hemodialysis (adjusted difference 12.0 points, 95% CI 3.9; 20.1). There were potentially clinically relevant differences between kidney transplantation and nocturnal hemodialysis on the domains “burden” (adjusted difference 11.1 points, 95% CI -2.6; 24.8), “social support” (adjusted difference 6.2, 95% CI -6.6; 19.1), and the physical composite score (adjusted difference 3.0, 95% CI -2.0; 8.1), but these were not significant.

Conclusions

After kidney transplantation, HRQOL is especially higher on the domain “effects of kidney disease” compared to nocturnal hemodialysis. This can be useful when counseling patients on nocturnal hemodialysis who may opt for transplantation.

Prevention and treatment of hyperphosphatemia in chronic kidney disease

Hyperphosphatemia has consistently been shown to be associated with dismal outcome in a wide variety of populations, particularly in chronic kidney disease (CKD). Compelling evidence from basic and animal studies elucidated a range of mechanisms by which phosphate may exert its pathological effects and motivated interventions to treat hyperphosphatemia. These interventions consisted of dietary modifications and phosphate binders. However, the beneficial effects of these treatment methods on hard clinical outcomes have not been convincingly demonstrated in prospective clinical trials. In addition, exposure to high amounts of dietary phosphate may exert untoward actions even in the absence of overt hyperphosphatemia. Based on this concept, it has been proposed that the same interventions used in CKD patients with normal phosphate concentrations be used in the presence of hyperphosphatemia to prevent rise of phosphate concentration and as an early intervention for cardiovascular risk. This review describes conceptual models of phosphate toxicity, summarizes the evidence base for treatment and prevention of hyperphosphatemia, and identifies important knowledge gaps in the field.

Daily Dialysis Kt/V and Flexible Schedules: Is it Possible to Control Efficiency, When and How?

Background

Daily hemodialysis is a promising treatment schedule but uniform criteria for defining efficiency are lacking.

Methods

On our daily dialysis (DD) schedule, duration is flexible (2–3 hours, patients are free to add up to 30min/session), Qb 250–350 mL/min; dialyser 1.6–1.8 m2. Study was performed on 12 pts on DD for ≥2 months, with ≥4 Kt/V on subsequent days, tested in the same laboratory. Goal: To evaluate variability and identify a simple method for weekly calculation, Kt/V was assessed for 133 sessions.

Results

On flexible DD, variability of Kt/V-session is high (relative error 4.9%-22%). On flexible schedules, within the time range chosen (2–3 hours) variability of average hourly Kt/V is lower (standard deviation: min (0.014; max (0.052 hour, relative error 4.9%-10%) allowing calculation of weekly Kt/V (averaging 3 sessions: relative error <6%) suitable for clinical practice.

Conclusions

Flexible schedules, allowing patients to increase treatment time, are an interesting clinical option, but a challenge for Kt/V assessment.

High-Intensity Hemodialysis: The Wave of the Future?

Various modalities of high-intensity hemodialysis are gathering increasing popularity. Some of the advantages of these new dialysis regimens are presented. Time and the increasing use of these novel approaches will ultimately determine their role in the overall management of patients with end-stage renal disease.

Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate, clinical, and laboratory outcomes: A 1-year retrospective observation study

INTRODUCTION

While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed.

METHODS

A 1-year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin).

FINDINGS

NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age-adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77-20.99, P = 0.04). They consumed less aluminum-based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol² /L² , P < 0.01), with similar hemoglobin levels.

DISCUSSION

NHHD appeared to offer higher employment rate, lower dosage of aluminum-based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong.

Frequent hemodialysis: history of the modality and assessment of outcomes

About 660,000 individuals have end-stage renal disease in the USA, the vast majority of whom are receiving standard, in-center, thrice-weekly hemodialysis (HD). The morbidity and mortality among patients receiving standard HD remain unacceptably high. Studies conducted over the past two decades have provided a substantial amount of information on the advantages and drawbacks of providing more frequent HD treatment, either in-center or at home. In this article I summarize these studies, focusing special attention on the randomized, cross-over study assessing outcomes in children who received either frequent, in-center HD or traditional, thrice-weekly, in-center HD performed by Laskin et al. (Pediatr Nephrol doi: 10.1007/s00467-017-3656-x , 2017).

In-Center Nocturnal Hemodialysis Versus Conventional Hemodialysis: A Systematic Review of the Evidence

BACKGROUND

Owing to its longer treatment duration-up to 8 hours per dialysis treatment-in-center thrice-weekly nocturnal hemodialysis (HD) is receiving greater attention. To better understand the evidence for in-center nocturnal HD, we sought to systematically review the literature to determine the effects of in-center nocturnal HD versus conventional HD on clinically relevant outcomes.

STUDY DESIGN

We searched MEDLINE, Embase, Evidence-Based Medicine Reviews (EBMR), Web of Science, and Scopus from the earliest date in the database to November 2016.

SETTING & POPULATION

Adults receiving in-center nocturnal HD compared with those receiving conventional HD.

SELECTION CRITERIA FOR STUDIES

All quasi-experimental and observational studies were considered; randomized trials were sought but not found.

PREDICTOR

Nocturnal vs conventional in-center HD.

OUTCOMES

Indexes of blood pressure and left ventricular hypertrophy, markers of anemia, measures of bone mineral metabolism, nutrition, quality of life, sleep quality, episodes of intradialytic hypotension, hospitalization, and mortality.

RESULTS

Of 2,086 identified citations, 21 met the inclusion criteria, comprising a total of 1,165 in-center nocturnal HD patients and 15,865 conventional HD patients. Although there was substantial heterogeneity in reporting of outcomes, we pooled data for measures of blood pressure, anemia, and mineral metabolism. Though heterogeneity was generally high, in-center nocturnal HD was associated with improved systolic blood pressure (-3.18 [95% CI, -5.58 to -0.78) mm Hg, increased hemoglobin levels (0.53 [95% CI, 0.11-0.94] g/dL), and lower serum phosphate levels (-0.97 [95% CI, -1.48 to -0.46] mg/dL).

LIMITATIONS

No randomized trials have been conducted to address the clinical effects of in-center nocturnal HD. The quality of the observational literature contributing to the results of this review was generally poor to moderate. Confounded outcomes are a significant concern. Publication bias and outcome reporting bias remain possibilities.

CONCLUSIONS

Relative to conventional HD, in-center nocturnal HD was associated with improvements in several clinically relevant outcomes. Other benefits may not have been detected due to small sample sizes of included studies; no prespecified outcome was worse with in-center nocturnal HD.

Length of Interdialytic Intervals Affects Morbidity and Mortality in Chronic Haemodialysis Patients

Background

Chronic in-center hemodialysis (HD) patients may experience more morbidity and mortality after the weekend. Since our Veterans Administration Hospital HD unit is closed on the weekend, non-traditional HD schedules were created. Some schedules contained a 4-day weekend compared to the usual 3-day weekend. We hypothesized that there are more frequent cardiovascular events (CVEs) and higher mortality after longer interdialytic intervals.

Methods

Patients (n=85) were placed on HD schedules as they became available. The usual interdialytic interval group consisted of patients dialyzing on Mon-Wed-Fri or Mon-Tue-Fri (longest interdialytic gap 3 days, n=29), and the long interdialytic interval group consisted of patients dialyzing on Mon-Wed-Thu, Mon-Tue-Thu, Tue-Wed-Fri, or Tue-Thu-Fri (longest interdialytic gap 4 days, n=56).

Results

All-cause mortality was not different between groups, and CVEs occurred more frequently in the usual interdialytic interval group (maybe due to higher mean potassium and phosphorus concentrations). However, within each group, a similar pattern of CVE occurrence as a function of time after dialysis was observed. Compared to CVEs occurring during the 2 days after HD (the lowest frequency), CVEs occurred 2–3 times more frequently during and immediately after HD and 5–7 times more frequently during the third and fourth days after HD. The greatest risk of CVE occurred during the fourth day after HD, which exists only in the long interdialytic interval group.

Conclusion

In chronic HD patients, CVEs are most likely to occur after the longest interdialytic intervals.

Association between daily haemodialysis, access to renal transplantation and patients' survival in France

AIM

Daily haemodialysis improves patients' quality of life and blood purification, but its effect on survival remains controversial. The aim of this study was to analyze the association between daily haemodialysis and renal transplantation and survival in France.

METHODS

This was an observational cohort study based on the French REIN registry. All incident patients ≥18 years old who started daily haemodialysis in France between 2003 and 2012 were included. Using a propensity score, 575 patients on daily haemodialysis were matched with 1696 patients receiving thrice-weekly haemodialysis. Survival analysis was performed using the Cox model. Access to the renal transplant waiting list and renal transplantation were analyzed using the Fine and Gray model.

RESULTS

Daily haemodialysis was not independently associated with reduced access to transplant waiting list, whereas, major comorbidities remained associated with restricted waitlisting after multivariate analysis adjusted for confounding factors. After being waitlisted, the cumulative incidence of renal transplantation was lower for the daily haemodialysis than for the thrice-weekly haemodialysis group (SHR = 0.72, 95%CI: 0.56-0.91). The risk of death was significantly higher in the daily haemodialysis group (HR_adjusted  = 1.58, 95%CI: 1.4-1.8). Major comorbidities were associated with higher risk of death and lower likelihood of receiving a renal transplant during the follow-up period.

CONCLUSION

Our study showed that in France, the likelihood of undergoing renal transplantation after being waitlisted was lower for patients on daily haemodialysis than those on thrice-weekly haemodialysis. Moreover, daily haemodialysis was associated with higher risk of death, even after taking into account age and all major comorbidities.

Comparisons of amino acids, body constituents and antioxidative response between long-time HD and normal HD

Introduction Oxidative stress is one of the main mediators of progression of chronic kidney diseases (CKD). Nuclear factor E2-related factor 2 (Nrf2) is the transcription factor of antioxidant and detoxifying enzymes and related proteins which play an important role in cellular defense. Long-time hemodialysis (HD) therapy (8 hours) has been considered to be more beneficial compared to normal HD therapy (4 hours). We investigated oxidative response related to Nrf2 in peripheral blood mononuclear cells (PBMCs) of long-time HD and normal HD patients. Methods Eight adult long-time HD therapy patients (44.5 ± 3.0 years) and 10 normal HD therapy patients (68.1 ± 2.7 years) were enrolled. PBMCs were isolated and processed for expression of Nrf2 and its related genes by qRT-PCR. Plasma indoxyl sulfate, amino acids, and body constituents were measured. Findings Plasma indoxyl sulfate was significantly low after long-time HD therapy compare to that of normal HD therapy. Although, skeletal muscle mass, lean body mass, mineral and protein were significantly decreased 2 months in normal HD patients, those in long-time HD patients were significantly increased after 2 months. Almost of amino acids were significantly decreased after HD therapy in both HD therapies. Plasma amino acids were significantly low in long-time HD patients compared to normal HD patients. In PBMCs, the expression of Nrf2 was significantly decreased and hemooxygenase-1 expression was significantly increased in long-time HD compared to normal HD. Conclusion These observations indicate the beneficial effects of in long-time HD in improving oxidative stress in patients.

Modeling the Dose of Home Dialysis

The growing interest in daily dialysis and combined continuous and intermittent dialysis treatments has created the need for a dialysis dosing model that is valid over a wide range of dosing frequency and intensity. Three models have been described for this purpose and are reviewed here. They have in common the concept of a continuous clearance value which is equivalent to the summed intermittent dialysis prescribed. The continuous clearance models all define a point on the saw-toothed blood urea nitrogen (BUN) concentration profile and calculate the continuous clearance required to achieve this at the same urea generation rate. The points modeled are the peak predialysis concentration (pkKt/V), the average Co (standard Kt/V, stdKt/V), and time-averaged urea concentration (TAC), which is termed equivalent renal clearance (EKRt/V). At the present time the only data for evaluation of clinical relevance of the three models is continuous ambulatory peritoneal dialysis (CAPD) outcome. The stdKt/V predicts that optimal CAPD outcome requires weekly stdKt/V 2.0, while the pkKt/V and EKRt/V models predict optimal doses of 1.8 and 3.0. These results suggest that the stdKt/V is the most realistic model, but data over much higher levels of therapy are not yet available to judge generalizability. The stdKt/V model was used to assess dose in two hemodialysis studies with 5 to 6 dialyses per week and showed that in one study the stdKt/V was only 2.0, while in the second study it was 5.6. These results show that dose can vary widely with a similar number of dialyses per week and point to the need for a generalized dosing model to guide and compare studies of daily home dialysis.

French patients on daily hemodialysis: clinical characteristics and treatment trajectories

BACKGROUND

Increasing the weekly frequency of hemodialysis sessions has positive effects, on the control of several biological data of patients. However, knowledge about Daily HemoDialysis (DHD) practices is limited in France. The aim of the present study was to describe the characteristics and treatment trajectories of all French patients undergoing DHD.

METHODS

All patients older than 18 years who started DHD between 2003 and 2012 in France were included and followed until December 31, 2013. The patients' demographic and clinical characteristics and treatment modalities were extracted from the French Renal Epidemiological and Information Network (REIN) registry.

RESULTS

During the inclusion period, 753 patients started DHD in France. Based on their median age (64 years), patients were classified in two groups: "old" group (≥64 years) and "young" group (<64 years). Patients in the old group had more comorbidities than in the young group: 48 % had diabetes (vs 29 % in the young group), 17 % an active malignancy (vs 10 %) and 80 % ≥1 cardiovascular disease (vs 41 %). Concerning patients' treatment trajectories, 496 (66 %) patients started with another dialysis before switching to DHD and 257 (34 %) directly with DHD. At the end of the follow-up, 69 % of patients in the old group were dead (27.4 % in the young group) and kidney transplantation was more frequent in the young group (30.4 % vs 0.5 %).

CONCLUSION

In France, DHD is proposed not only to young in rather good clinical conditions and waiting for kidney transplantation, but also to old and frail patients with higher mortality.

Nutritional Status in Nocturnal Hemodialysis Patients - A Systematic Review with Meta-Analysis

Background

Hemodialysis patients experience an elevated risk of malnutrition associated with increased morbidity and mortality. Nocturnal hemodialysis (NHD) results in more effective removal of waste products and fluids. Therefore, diet and fluid restrictions are less restricted in NHD patients. However, it is ambiguous whether transition from conventional hemodialysis (CHD) to NHD leads to improved intake and nutritional status. We studied the effect of NHD on protein intake, laboratory indices of nutritional status, and body composition.

Study design

Systematic review with meta-analysis.

Population

NHD patients.

Search strategy

Systematic literature search from databases, Medline, Cinahl, EMBASE and The Cochrane Library, to identify studies reporting on nutritional status post-transition from CHD to NHD.

Intervention

Transition from CHD to NHD.

Outcomes

Albumin, normalized protein catabolic rate (nPCR), dry body weight (DBW), body mass index (BMI), phase angle, protein intake, and energy intake.

Results

Systematic literature search revealed 13 studies comprising 282 patients that made the transition from CHD to NHD. Meta-analysis included nine studies in 229 patients. In control group controlled studies (n = 4), serum albumin increased significantly from baseline to 4–6 months in NHD patients compared with patients that remained on CHD (mean difference 1.3 g/l, 95% CI 0.02; 2.58, p = 0.05). In baseline controlled studies, from baseline to 4–6 months of NHD treatment, significant increases were ascertained in serum albumin (mean difference (MD) 1.63 g/l, 95% CI 0.73–2.53, p<0.001); nPCR (MD 0.16 g/kg/day; 95% CI 0.04–0.29, p = 0.01); protein intake (MD 18.9 g, 95% CI 9.7–28.2, p<0.001); and energy intake (MD 183.2 kcal, 95% CI 16.8–349.7, p = 0.03). Homogeneity was rejected only for nPCR (baseline versus 4–6 months). DBW, BMI, and phase angle did not significantly change. Similar results were obtained for comparison between baseline and 8–12 months of NHD treatment.

Limitations

Most studies had moderate sample sizes; some had incomplete dietary records and relatively brief follow-up period. Studies markedly differed with regard to study design.

Conclusions

NHD is associated with significantly higher protein and energy intake as well as increases in serum albumin and nPCR. However, the data on body composition are inconclusive.

Why take the chance? A qualitative grounded theory study of nocturnal haemodialysis recipients who decline kidney transplantation

OBJECTIVE

The objective of this study was to examine the factors that influence decision-making to forgo transplantation in favour of remaining on nocturnal haemodialysis (NHD).

DESIGN

A grounded theory approach using in-depth telephone interviewing was used.

SETTING

Participants were identified from 2 tertiary care renal programmes in Canada.

PARTICIPANTS

The study participants were otherwise eligible patients with end-stage renal disease who have opted to remain off of the transplant list. A total of 7 eligible participants were interviewed. 5 were male. The mean age was 46 years.

ANALYSIS

A constant comparative method of analysis was used to identify a core category and factors influencing the decision-making process.

RESULTS

In this grounded theory study of people receiving NHD who refused kidney transplantation, the core category of 'why take a chance when things are going well?' was identified, along with 4 factors that influenced the decision including 'negative past experience', 'feeling well on NHD', 'gaining autonomy' and 'responsibility'.

CONCLUSIONS

This study provides insight into patients' thought processes surrounding an important treatment decision. Such insights might help the renal team to better understand, and thereby respect, patient choice in a patient-centred care paradigm. Findings may also be useful in the development of education programmes addressing the specific concerns of this population of patients.

Patient selection and training for home hemodialysis

Patient selection and training is arguably the most important step toward building a successful home hemodialysis (HD) program. We present a step-by-step account of home HD training to guide providers who are developing home HD programs. Although home HD training is an important step in allowing patients to undergo dialysis in the home, there is a surprising lack of systematic research in this field. Innovations and research in this area will be pivotal in further promoting a higher acceptance rate of home HD as the renal replacement therapy of choice.

Therapeutic applications of circadian rhythms for the cardiovascular system

The cardiovascular system exhibits dramatic time-of-day dependent rhythms, for example the diurnal variation of heart rate, blood pressure, and timing of onset of adverse cardiovascular events such as heart attack and sudden cardiac death. Over the past decade, the circadian clock mechanism has emerged as a crucial factor regulating these daily fluctuations. Most recently, these studies have led to a growing clinical appreciation that targeting circadian biology offers a novel therapeutic approach toward cardiovascular (and other) diseases. Here we describe leading-edge therapeutic applications of circadian biology including (1) timing of therapy to maximize efficacy in treating heart disease (chronotherapy); (2) novel biomarkers discovered by testing for genomic, proteomic, metabolomic, or other factors at different times of day and night (chronobiomarkers); and (3) novel pharmacologic compounds that target the circadian mechanism with potential clinical applications (new chronobiology drugs). Cardiovascular disease remains a leading cause of death worldwide and new approaches in the management and treatment of heart disease are clearly warranted and can benefit patients clinically.

Delivering home hemodialysis: is there still a role for real-time treatment monitoring?

Remote real-time treatment monitoring for home hemodialysis (HHD) was driven by concerns over patient safety in the early era of HHD. However, decades of clinical experience supported by objective data suggest that HHD is very safe and that remote monitoring is unlikely to avert serious adverse events. As a result, such remote monitoring is not routinely offered in the current era and is generally considered an unnecessary expense. However, a one-size-fits-all approach to abandon remote monitoring may overlook potential opportunities: to improve the clinical care of patients dialyzing at home; and to give patients the confidence to perform HHD in an unsupervised setting.