Intensified hemodialysis in adults, and in children and adolescents.

Abstract

There are now almost 70 000 dialysis patients in Germany. Conventional hemodialysis does not adequately compensate for malnutrition, arterial hypertension, renal osteopathy, and diminished performance ability. Various strategies for intensified hemodialysis have been implemented in an attempt to lower the considerable morbidity and mortality of end-stage renal failure. We selectively review the literature on intensified dialysis in adults, children, and adolescents. In a randomized, controlled trial (RCT), a group of patients undergoing conventional dialysis was compared to a group undergoing brief, daily dialysis. Daily dialysis significantly improved the combined endpoint of left-ventricular hypertrophy or death (hazard ratio [HR] 0.61). In contrast, another, retrospective study found daily dialysis to be associated with higher mortality (15.6 vs. 10.9 deaths, HR 1.6). A prospective case-control study found nocturnal intermittent hemodialysis to be associated with lower mortality than conventional dialysis (1.77 vs. 6.23 per 100 patient-years); this result was confirmed in a further, retrospective study. An RCT on nocturnal dialysis performed every night revealed a significant regression of left-ventricular mass, yet the patients' quality of life improved only in individual domains specifically related to renal function. Small-scale studies of intensified hemodialysis in children and adolescents have found that it leads to a higher growth rate and weight gain. Intensified hemodialysis techniques improve arterial blood pressure, uremia-associated variables, and psychosocial variables. They also lower the necessary doses of antihypertensive drugs and phosphate binders. Dietary restrictions need not be as stringent. Further prospective trials are needed for a reliable assessment of the effect of intensified hemodialysis on mortality and quality of life.