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Journal ArticleDOI

Outcomes Associated with In-Center Nocturnal Hemodialysis from a Large Multicenter Program

01 Feb 2010-Clinical Journal of The American Society of Nephrology (American Society of Nephrology)-Vol. 5, Iss: 2, pp 220-226
TL;DR: Patients who were on INHD exhibited excellent quality indicators, with better survival and lower hospitalization rates, and the relative contributions of patient selection versus effect of therapy on outcomes remain to be elucidated in prospective clinical trials.
Abstract: Background and objectives: The objective of this study was to evaluate epidemiology and outcomes of a large in-center nocturnal hemodialysis (INHD) program. Design, setting, participants, & measurements: This case-control study compared patients who were on thrice-weekly INHD from 56 Fresenius Medical Care, North America facilities with conventional hemodialysis patients from 244 facilities within the surrounding geographic area. All INHD cases and conventional hemodialysis control subjects who were active as of January 1, 2007, were followed until December 31, 2007, for evaluation of mortality and hospitalization. Results: As of January 1, 2007, 655 patients had been on INHD for 51 ± 73 d. Patients were younger, there were more male and black patients, and vintage was longer, but they had less diabetes compared with 15,334 control subjects. Unadjusted hazard ratio was 0.59 for mortality and 0.76 for hospitalization. After adjustment for case mix and access type, only hospitalization remained significant. Fewer INHD patients were hospitalized (48 versus 59%) with a normalized rate of 9.6 versus 13.5 hospital days per patient-year. INHD patients had greater interdialytic weight gains but lower BP. At baseline, hemoglobin values were similar, whereas albumin and phosphorus values favored INHD. Mean equilibrated Kt/V was higher in INHD patients related to longer treatment time, despite lower blood and dialysate flow rates. Conclusions: Patients who were on INHD exhibited excellent quality indicators, with better survival and lower hospitalization rates. The relative contributions of patient selection versus effect of therapy on outcomes remain to be elucidated in prospective clinical trials.

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Citations
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Journal ArticleDOI
TL;DR: In this article, the authors conducted a systematic review of the literature to determine the effects of in-center nocturnal hemodialysis (in-center HD) versus conventional HD on clinically relevant outcomes.

27 citations

Journal ArticleDOI
TL;DR: The introduction of a nocturnal dialysis program to an existing intensified HD program significantly improved the uremia-associated parameters, nutrition and hemodynamic stability of seven patients.
Abstract: To overcome the deleterious consequences of conventional dialysis, intensified dialysis programs have been developed and their feasibility and beneficial effects in children demonstrated. To investigate whether such a program can be further improved, we implemented hemodialfiltration within an established pediatric in-center, nocturnal hemodialysis program. After being started on conventional hemodialysis (HD), seven patients were switched to intermittent nocturnal hemodialysis (NHD) for 3 months, then to intermittent nocturnal online-hemodiafiltration (NHDF) for a further 3 months and finally back to NHD. Uremia-associated parameters, predialytic blood pressure, intradialytic events, protein catabolic rate and levels of albumin, vitamins and trace elements were investigated. Dialysis-related medication and dietary restrictions were also registered. Phosphate and intact parathyroid hormone levels were reduced after the switch from HD to NHD and NHDF. Dialysis dose (Kt/V) was increased in patients on NHD and NHDF; however, Kt/V was significantly higher with NHDF than NHD. Blood pressure was significantly reduced in patients on NHD and NHDF despite the reduction in antihypertensive medication; albumin levels were significantly higher on NHD and NHDF, indicating improved nutritional status; protein catabolic rate was also increased. Vitamins and trace elements remained unchanged. All dietary restrictions could be lifted in patients on NHD and NHDF. The introduction of a nocturnal dialysis program to an existing intensified HD program significantly improved the uremia-associated parameters, nutrition and hemodynamic stability of our seven patients. At least during our observational period, hemodiafiltration was able to further improve the existing HD program by increasing the Kt/v.

26 citations

Journal ArticleDOI
TL;DR: This review examines the available RCT evidence on interventions aimed at preventing cardiovascular events in people with kidney disease to identify beneficial treatments as well as current gaps in knowledge that should be a priority for future research.
Abstract: Cardiovascular disease is the leading cause of death and morbidity in people with chronic kidney disease (CKD) making measures to modify cardiovascular risk a clinical priority. The relationship between risk factors and cardiovascular outcomes is often substantially different in people with CKD compared with the general population, leading to uncertainty around pathophysiological mechanisms and the validity of generalizations from the general population. Furthermore, published reports of subgroup analyses from clinical trials have suggested that a range of interventions may have different effects in people with kidney disease compared with those with normal kidney function. There is a relative scarcity of randomized controlled trials (RCTs) conducted in CKD populations, and most such trials are small and underpowered. As a result, evidence to support cardiovascular risk modification measures for people with CKD is largely derived from small trials and post hoc analyses of RCTs conducted in the general population. In this review, we examine the available RCT evidence on interventions aimed at preventing cardiovascular events in people with kidney disease to identify beneficial treatments as well as current gaps in knowledge that should be a priority for future research.

25 citations


Cites background from "Outcomes Associated with In-Center ..."

  • ...Observational studies demonstrate that various forms of extended haemodialysis are associated with a range of improved biochemical and clinical outcomes [Lacson et al. 2010; van Eps et al. 2010; Walsh et al. 2005; Innes et al. 1999]....

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  • ...However, it is widely recognized that patients who opt for such treatments have characteristics associated with better prognosis such that better outcomes would be expected even in the absence of a treatment effect [Lacson et al. 2010; van Eps et al. 2010; Powell et al. 2009; Innes et al. 1999]....

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Journal ArticleDOI
TL;DR: Across a wide array of metabolites examined, extended duration hemodialysis was associated with modest changes in the plasma metabolome, with most differences relating to metabolite increases, despite increased dialysis time.
Abstract: Background and objectives In-center, extended duration nocturnal hemodialysis has been associated with variable clinical benefits, but the effect of extended duration hemodialysis on many established uremic solutes and other components of the metabolome is unknown We determined the magnitude of change in metabolite profiles for patients on extended duration nocturnal hemodialysis Design, setting, participants, & measurements In a 52-week prospective, observational study, we followed 33 patients receiving conventional thrice weekly hemodialysis who converted to nocturnal hemodialysis (7–8 hours per session, three times per week) A separate group of 20 patients who remained on conventional hemodialysis (3–4 hours per session, three times per week) served as a control group For both groups, we applied liquid chromatography-mass spectrometry–based metabolite profiling on stored plasma samples collected from all participants at baseline and after 1 year We examined longitudinal changes in 164 metabolites among those who remained on conventional hemodialysis and those who converted to nocturnal hemodialysis using Wilcoxon rank sum tests adjusted for multiple comparisons (false discovery rate Results On average, the nocturnal group had 96 hours more dialysis per week than the conventional group Among 164 metabolites, none changed significantly from baseline to study end in the conventional group Twenty-nine metabolites changed in the nocturnal group, 21 of which increased from baseline to study end (including all branched-chain amino acids) Eight metabolites decreased after conversion to nocturnal dialysis, including l-carnitine and acetylcarnitine By contrast, several established uremic retention solutes, including p-cresol sulfate, indoxyl sulfate, and trimethylamine N-oxide, did not change with extended dialysis Conclusions Across a wide array of metabolites examined, extended duration hemodialysis was associated with modest changes in the plasma metabolome, with most differences relating to metabolite increases, despite increased dialysis time Few metabolites showed reduction with more dialysis, and no change in several established uremic toxins was observed

25 citations

Journal ArticleDOI
TL;DR: Care for the elderly with end-stage renal disease should be undertaken by a multidisciplinary team with special dedication to a multidimensional approach in this population.
Abstract: The number of geriatric patients on dialysis is increasing. This is due to demographic factors, a wider acceptance of elderly patients on dialysis, and an earlier start of dialysis in this patient group. Recent studies have questioned the effect of dialysis on quality of life in elderly patients with severe comorbidity and showed limited survival in this specific patient group. Therefore, the decision whether or not to start dialysis may be a difficult one for both the clinician and patient. Risk scores can be of help in facilitating shared decision making, but not as a tool to withhold dialysis. However, in the elderly patient with severe comorbidity, conservative care can sometimes be a reasonable alternative to dialysis. In the process of shared decision making, a balance should be pursued between life expectancy and quality of life. If the decision to initiate dialysis is taken, choices have to be made regarding dialysis modality and treatment prescription. If adequate support is provided, assisted peritoneal dialysis can be an acceptable alternative to hemodialysis. Care for the elderly with end-stage renal disease should be undertaken by a multidisciplinary team with special dedication to a multidimensional approach in this population.

25 citations

References
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Journal ArticleDOI
TL;DR: Patients undergoing hemodialysis thrice weekly appear to have no major benefit from a higher dialysis dose than that recommended by current U.S. guidelines or from the use of a high-flux membrane.
Abstract: Background The effects of the dose of dialysis and the level of flux of the dialyzer membrane on mortality and morbidity among patients undergoing maintenance hemodialysis are uncertain. Methods We undertook a randomized clinical trial in 1846 patients undergoing thrice-weekly dialysis, using a two-by-two factorial design to assign patients randomly to a standard or high dose of dialysis and to a low-flux or high-flux dialyzer. Results In the standard-dose group, the mean (±SD) urea-reduction ratio was 66.3±2.5 percent, the single-pool Kt/V was 1.32±0.09, and the equilibrated Kt/V was 1.16±0.08; in the high-dose group, the values were 75.2±2.5 percent, 1.71±0.11, and 1.53±0.09, respectively. Flux, estimated on the basis of beta2-microglobulin clearance, was 3±7 ml per minute in the low-flux group and 34±11 ml per minute in the high-flux group. The primary outcome, death from any cause, was not significantly influenced by the dose or flux assignment: the relative risk of death in the high-dose group as com...

1,670 citations

Journal ArticleDOI
TL;DR: Longer TT and higher Kt/V were independently as well as synergistically associated with lower mortality, and a randomized clinical trial of longer dialysis sessions in thrice-weekly HD is warranted.

490 citations

Journal ArticleDOI
TL;DR: NHD is more effective in controlling serum phosphate levels than CHD, allowing patients to discontinue their phosphate binders completely and to ingest a more liberal diet.

342 citations

Journal ArticleDOI
TL;DR: In patients with end-stage renal disease, inadequate hemodialysis is associated with a suboptimal response to erythropoietin therapy and increasing the intensity of dialysis in patients with anemia who are receiving inadequate dialysis results in a significant increase in the hematocrit.
Abstract: Background Anemia (characterized by a hematocrit of 30 percent or lower) persists in 40 to 60 percent of patients treated for end-stage renal disease with maintenance hemodialysis, despite concomitant erythropoietin (epoetin) therapy. We tested the hypothesis that inadequate dialysis is a key reason for the insufficient response to erythropoietin in patients with end-stage renal disease who are receiving hemodialysis. Methods we prospectively studied 135 randomly selected patients undergoing hemodialysis who had been receiving intravenous erythropoietin for at least four months. The adequacy of dialysis was assessed by measuring the percent reduction in the blood urea nitrogen concentration and the serum albumin concentration. The hematocrit was measured weekly for four weeks, transferrin saturation was measured, and coexisting illnesses were documented. To determine the effect of an increased level of dialysis on the hematocrit, the thrice-weekly schedule of dialysis was increased to raise the mean urea-...

252 citations

Journal ArticleDOI
TL;DR: The Frequent Hemodialysis Network Trials Group is conducting two multicenter randomized trials of 250 subjects each, comparing conventional three times weekly HD with (1) in-center daily HD and (2) home nocturnal HD, during which feasibility of randomization, ability to deliver the interventions, and adherence will be evaluated.

186 citations


"Outcomes Associated with In-Center ..." refers background or result in this paper

  • ...Patients (n % ) 655 (4) 15,334 (96) Age (yr; mean SD) 51....

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  • ...While results from the Frequent Hemodialysis Network on two randomized trials that evaluated outcomes from short daily in-center and long nightly home dialysis are pending (4), two recent publications renewed interest in the potential impact of longer hemodialysis session length, also referred to as treatment time (TT), to improve survival within the most prevalent practice of a thrice-weekly regimen....

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  • ...The growth of INHD therapy is remarkable considering the barriers to implementing INHD in the United States: (1) Criticism that historical outcome data were skewed by highly selected patients; (2) competitive “modality choice” because many patients who are eligible for INHD are often also eligible for home dialysis options; (3) logistical issues facing clinic managers from accommodating longer TT for patients in outpatient dialysis units that are filled to capacity; (4) the constant struggle to convince patients to stay longer for in-center treatments, even by just a few minutes; (5) local staffing issues as a result of a variable supply of dialysis nurses and patient care technicians who are willing to do a night shift; and (6) increased cost of providing therapy without additional reimbursement, becoming apparent when patient participation falls below critical mass....

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