https://www.kidney.org/sites/default/files/docs/kdoqi-ckd-mbd-commentary.pdf

KDOQI US commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD-Mineral and Bone Disorder (CKD-MBD).

Department of Renal Medicine, St James’s University Hospital, Leeds, UK, Nephrology Department, Reina Sofia University Hospital, Cordoba, Spain, Division of Nephrology and Dialysis, Bolognini Hospital, Seriate, Italy, Department of Medicine, Division of Nephrology, Ege University Medical Faculty, Izmir, Turkey, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Departement de Nephrologie JE 2411 Denutrition des Maladies Chroniques, Hopital E Herriot, France, Department of Diagnostic and Interventional Radiology, Helios Klinikum Wuppertal, University Hospital Witten/Herdecke, Germany, Medical Faculty University of Cologne, Medicine Clinic I, Hospital Merheim, Germany (retired), Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, The Netherlands, Nephrology Unit, SM Annunziata Hospital, Florence, Italy, Department of Surgery, University Hospital Maastricht, The Netherlands, Department of Nephrology, Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK (retired), Department of Medicine, Division of Nephrology, University Hospital, Wurzburg, Germany, Department of Nephrology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands and Nephrology Section, Department of Internal Medicine, University Hospital, Ghent, Belgium

/pdf/ebpg-guideline-on-dialysis-strategies-287fv6me2t.pdf

EBPG guideline on dialysis strategies

Mortality is markedly elevated in hemodialysis (HD) patients. Between 30 and 50% of prevalent patients have elevated serum levels of inflammatory markers such as C-reactive protein and IL-6. The presence of inflammation, chronic or episodic, has been found to be associated with increased mortality risk. The causes of inflammation are multifactorial and include patient-related factors, such as underlying disease, comorbidity, oxidative stress, infections, obesity, and genetic or immunologic factors, or on the other side, HD-related factors, mainly depending on the membrane biocompatibility and dialysate quality. The adequate knowledge of these causes and their prevention or treatment if possible may contribute to improving the inflammatory state of patients who are on HD and possibly their mortality.

/pdf/inflammatory-syndrome-in-patients-on-hemodialysis-42u1m2c9dr.pdf

Inflammatory Syndrome in Patients on Hemodialysis

A systematic review of the effect of nocturnal hemodialysis on blood pressure, left ventricular hypertrophy, anemia, mineral metabolism, and health-related quality of life.

Frequent Hemodialysis Network (FHN) randomized trials: study design.

https://www.ajkd.org/article/S0272-6386(03)00534-1/pdf

Calcium and phosphate balance with quotidian hemodialysis.

Interest in quotidian (daily) hemodialysis (HD) is growing. Some advocate short-hours high-efficiency daily HD (SDH) and others long-hours slow-flow nocturnal HD (NH) while the patient is asleep, both being used 5 to 7 d/week. The London Daily/Nocturnal Hemodialysis Study was the first attempt to obtain data of SDH and NH that may be compared with conventional thrice weekly HD (CH). This was a 4-yr observational study designed to enter and follow 40 patients: 10 receiving SDH, 10 receiving NH, and 20 receiving CH. The CH patients were cohort control subjects matched for each SDH and NH patient by age, gender, comorbidity, and original dialysis modality (in-center, home, self-care, or satellite HD). All SDH and NH treatments were at home. Data collection to December 2001 was analyzed. Then enrollment had been completed and all patients had been followed for 15 mo, eight SDH plus six NH for 18 mo, seven SDH plus six NH for 21 mo, and seven SDH and five NH for 24 mo. This report gives data on calcium and phosphorus metabolism in these patients. All patients were initially dialyzed against a 1.25-mmol/L calcium bath. Predialysis serum calcium levels became lower in NH versus SDH patients by the first month and at 9 mo were 2.67 +/- 0.25 mmol/L (M +/- SD) in SDH, 2.40 +/- 0.16 mmol/L in NH, and 2.52 +/- 0.21 mmol/L in CH (SDH versus NH, P = 0.038; SDH versus CH versus NH, NS). Predialysis phosphorus levels were better controlled by NH than by SDH or CH, and with NH, all phosphate binders were discontinued. By 12 mo, a rise in bone alkaline phosphatase was seen in NH patients (but not in SDH or CH patients), which peaked at 15 to 18 mo (NH 191 IU/L +/- 70; SDH 82 +/- 34; CH 80 +/- 36; P < 0.002) and similarly with intact parathyroid hormone (iPTH) levels (NH 159 pmol/L +/- 75; SDH 13.1 +/- 10; CH 18 +/- 18; P < 0.00001). Because of these changes, the dialysate calcium concentration was increased to 1.75 mmol/L for the NH patients. Postdialysis calcium then rose to 2.57 +/- 0.21, and alkaline phosphatase and iPTH normalized completely by 21 mo. These observations prompted mass balance studies that showed that a 1.25-mmol/L calcium dialysate was associated with a mean net calcium loss of 2.1 mmol/h of dialysis time, whereas 1.75-mmol/L calcium dialysate provides a net gain of 3.7 mmol/h. In addition, the mass balance studies showed that phosphate removal by NH (43.5 +/- 20.7 mmol) was significantly (P < 0.05) higher than by SHD (24.2 +/- 13.9 mmol) but not by CH (34.0 +/- 8.7 mmol) on a per-treatment basis. With the increased frequency of treatments provided by quotidian dialysis, the weekly phosphorus removal (261.2 +/- 124.2 mmol) by NH was significantly higher than by SDH (P = 0.014) and CH (P = 0.03). This allowed the discontinuation of P binders in the NH group, which in turn eliminated approximately 8 g elemental Ca/wk oral intake. This, together with a 4 g elemental Ca/wk dialysate loss induced by a 1.25-mmol/L Ca bath, explains the changes in Ca, alkaline phosphatase, and iPTH seen in the NH patients. The SDH patients have weekly dialysis times similar to CH and still require P binders and do not become Ca deficient using 1.25-mmol/L Ca dialysate. With NH but not SDH, an elevated dialysate Ca concentration is required.

Nocturnal but not Short Hours Quotidian Hemodialysis Requires an Elevated Dialysate Calcium Concentration

It has been well-documented that Nocturnal Home Hemodialysis (NHH) is a superior form of treatment for patients undergoing chronic renal replacement therapy. However, documentation as to the actual type of patient suitable to perform this treatment at home is scarce. Patients who have significant comorbities have routinely received their treatment in a supervised setting (in-hospital or limited care) which is a much more expensive modality. We believed these patients could successfully perform NHH and do so at less cost.

The London Health Sciences Centre in London, Canada has recently completed a 3 year study utilizing matched cohort controls where patients have been treated with either Short Hour Daily Hemodialysis (SHDH) or NHH. Data collected includes biochemical, clinical and economical for 12 months retrospective on CH and 18 months on the selected daily therapy. Quality of Life data was obtained with disease specific questionnaires and the SF –36. Costs per Quality Adjusted Life Year was obtained with the Health Utilities Index tool. This case history of a very motivated 40 year old female with antiphospholipid antibody syndrome, bilateral amputation, uncontrolled hypertension and seizure disorder provides concrete data that not only has the cost of her health care diminished significantly (from $188,542.26 in the retrospective year to $80,249.76 Canadian dollars cost per patient year on NHH) but her Quality of Life has also dramatically improved. She was able to perform this treatment independently.

Patients currently dialyzing in supervised settings should be carefully assessed to determine if they are suitable to perform NHH and thereby experience benefits derived from the therapy. Expensive dialysis in overcrowded hospital units could also be diminshed and coupled with the approaching nursing shortage all parties will benefit.

Laurie Clement

Papers

Calcium and phosphate balance with quotidian hemodialysis.

Nocturnal but not Short Hours Quotidian Hemodialysis Requires an Elevated Dialysate Calcium Concentration

Nocturnal Home Hemodialysis Can Be Successful in Extremely Complicated Patients – A Case History.