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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TL;DR: Compared with CHD, INHD improves myocardial fibrosis and left ventricular function, and control of serum phosphorus is associated with the improvement of myocardia fibrosis.
Abstract: Ultrasonic tissue characterization with integrated backscatter (IBS) offers a promising method for the noninvasive assessment of myocardial fibrosis and contractile performance. The aim of this study was to investigate the effect of thrice-weekly in-center nocturnal hemodialysis (INHD) and conventional hemodialysis (CHD) on myocardial fibrosis and left ventricular function in end-stage renal disease patients. Thirty-two INHD and 58 matched CHD patients were enrolled; baseline and 12-month measures of blood pressure (BP), serum calcium and phosphorus, echocardiographic left ventricular mass index (LVMI) and left ventricular function, the myocardial calibrated IBS (C-IBS), and systodiastolic cyclical variations in IBS (CV-IBS) were collected. The baseline characteristics were similar between groups, except that serum phosphorus and calcium × phosphorus were higher in the INHD group. At 12-month follow-up, there was a significant decrease in the mean C-IBS (-20.2 ± 3.7 to -28.1 ± 4.0 dB, P<0.01) and a significant increase in CV-IBS (5.0 ± 1.5 to 7.1 ± 1.6 dB, P<0.01) in INHD patients. Multivariate analysis showed that the mean C-IBS was positively related to SBP, DBP, LVMI, serum phosphorus, and left atrial volume index and inversely related to midwall fractional shortening, transmitral E/A ratio, and E(m) . The mean CV-IBS was positively correlated with left ventricular midwall fractional shortening, E/A ratio, E(m) and inversely correlated with SBP, DBP, LVMI, serum phosphorus, E/E(m) , and left atrial volume index. There was no significant change in the mean C-IBS, mean CV-IBS, and LVMI in the CHD group. Compared with CHD, INHD improves myocardial fibrosis and left ventricular function, and control of serum phosphorus is associated with the improvement of myocardial fibrosis. Improvement of myocardial fibrosis contributes to the reduction of left ventricle hypertrophy.
24 citations
TL;DR: Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD and the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis.
Abstract: Background:Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the c...
22 citations
TL;DR: This study revealed that longer HD facilitates volume control and improves nutritional status.
Abstract: Background: This prospective cohort study compared the changes in body water composition and nutritional parameters measured with multifrequency bioimpedance analysis between 8-hour three times weekly nocturnal hemodialysis (NHD) and 4-hour conventional hemodialysis (CHD) patients. Patients and Methods: 55 patients on CHD and 57 patients on NHD were included in the study. Multifrequency bioimpedance analysis was performed at baseline and at the 12th month. The primary outcomes of the study were changes in extracellular water (ECW), fat mass, dry lean mass and phase angle. Secondary outcomes of the study included changes in blood pressure and biochemical parameters related to nutrition and inflammation. Results: ECW/height values decreased in the NHD group, while they increased in the CHD group. Fat mass, dry lean mass, and serum albumin increased and high sensitive CRP decreased in the NHD group but did not change in the CHD group. When changes in parameters from baseline to the 12th month between the groups were compared, NHD was associated with improvement in volume parameter including ECW/height (difference -0.44 l/m, p Conclusion: This study revealed that longer HD facilitates volume control and improves nutritional status.
20 citations
TL;DR: A review of how long nocturnal hemodialysis treatments have impact on the clearance of small and larger retention products, and how these treatments influence quality of life and survival is examined.
Abstract: PURPOSE OF REVIEW Conventional hemodialysis is often an incomplete treatment for uremia. People receiving hemodialysis often report a poor quality of life and suffer from an accelerated mortality rate. Nocturnal hemodialysis provides long treatments at night in the home or dialysis center. This review will examine how long nocturnal treatments have impact on the clearance of small and larger retention products, and how these treatments influence quality of life and survival. RECENT FINDINGS Nocturnal hemodialysis is more effective at clearing most small and middle molecule retention products, and has been associated with improvements in quality of life, especially in those domains related to the effects of kidney disease. Survival on nocturnal hemodialysis is higher than expected, and studies suggest that patients receiving nocturnal hemodialysis have a mortality rate that is about one third of what is seen in similar patients receiving conventional hemodialysis. SUMMARY Although impressive, it is difficult to be sure how much of the results of these studies is due to the duration and timing of dialysis and how much relates to patient level factors and residual confounding, and further research in this area is required.
20 citations
TL;DR: The evidence suggests that at least in some at‐risk patients, an individualized approach to the dialytic schedule and prescription is warranted, and physiologic rationale for this relationship is suggested.
Abstract: A thrice-weekly schedule dominates hemodialysis practice today. Inherent in such a schedule is a 72-hour interweek break over the weekend. A growing body of evidence suggests that this break may be associated with increased cardiovascular morbidity and mortality. Five recent studies have linked dialysis session timing to higher cardiovascular event rates, and have shed light on possible underlying physiologic mechanisms. We reviewed outcome data linking the "long break" to cardiovascular outcomes, and suggest physiologic rationale for this relationship while identifying knowledge gaps that require further study to inform discussions regarding the application and composition of individualized dialysis prescriptions. Further work is needed to determine the relative importance of electrolyte perturbations and hemodynamic shifts in the relationship between the long break and cardiovascular mortality. The evidence suggests that at least in some at-risk patients, an individualized approach to the dialytic schedule and prescription is warranted.
19 citations
Cites background from "Outcomes Associated with In-Center ..."
...In-center nocturnal HD, albeit performed thrice weekly, is another alternative treatment regimen that decreases the long break from 72 hours to <65 hours, and allows for lower UF rates and greater solute removal, including phosphorus (71)....
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References
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Baylor College of Medicine1, Cleveland Clinic2, University of Utah3, University of Illinois at Chicago4, National Institutes of Health5, University of Alabama6, Emory University7, Washington University in St. Louis8, University of California, Davis9, Tufts University10, Yeshiva University11, Harvard University12, University of Rochester13, Wake Forest University14, Vanderbilt University15, Duke University16
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
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
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
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
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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