Conventional Thrice-weekly Hemodialysis Research Articles

Incremental versus conventional haemodialysis in end-stage kidney disease: a systematic review and meta-analysis.

Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice-weekly haemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD compared with conventional HD were explored in this systematic review and meta-analysis. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization and mortality. A total of 36 articles (138939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD {odds ratio [OR] 0.87 [95% confidence interval (CI)] 0.72-1.04 and OR 0.67 [95% CI 0.43-1.05], respectively}. However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD [OR 0.44 (95% CI 0.27-0.72) and OR 0.31 (95% CI 0.25-0.39), respectively]. In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events [OR 0.22 (95% CI 0.08-0.63)] and mortality [OR 0.54 (95% CI 0.37-0.79)]. Vascular access complications, hyperkalaemia and volume overload were not statistically different between groups. Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.

Comparative Study between Incremental Hemodialysis and Conventional Thrice Weekly Hemodialysis in Prevalent Hemodialysis Patients

Abstract Background The concept of incremental dialysis is inherent to the increasingly accepted idea of a new patient-centered prescription of dialysis. Objective To compare the intervention arm (incremental HD) with the control arm (standard3 HD/week).Incident patients will be randomized to one of the two treatment groups in equal proportion. Primary outcome is the preservation of RKF assessed as time to anuria (UO < 100 mL/day). Secondary outcomes are all-cause mortality and significant events, including vascular access failure and associated interventions, cardiovascular events and hospital admissions. Patients and Methods Type of Study: Prospective cohort study. Study Setting: Multi centric patients selectionfrom hemodialysis units. Study period: 6 months. Results These findings support the assumption in hand, that a twice weekly regimen is in fact adequate for preserving the RKF. As regarding the occurrence of cerebrovascular events, chest pain, there were no statistically significant differences between the two groups. Arrhythmia was not recorded in the incremental group, while in the conventional group it was recorded in 2 patients with a percentage of 8.0%, and there was no statistically significant difference between the two groups; P-value was 0.490. As regarding the need for hospital admission, there was no significant difference between both groups. As regarding the occurrence of vascular access failure, it was recorded in 2 patients in the incremental group with a percentage of 8.0%, compared to 4 patients in the conventional group with a percentage of 16.0%. There was no significant difference between the two groups; P-value was 0.667. Conclusion HD, RCTs are lacking and are urgently needed. If the potential benefits of incremental HD will be confirmed by RCTs, then starting dialysis at a full dose will be subjecting patients to unnecessarily long or more frequent treatments for an unnecessarily long time, and at higher cost.

MO879: Prevalence, Recurrence and Seasonal Variation of Hyperkalaemia in Patients Receiving Thrice-Weekly Haemodialysis

Abstract BACKGROUND AND AIMS Prospective cohort studies have shown that among patients on haemodialysis, hyperkalaemia is strongly associated with excess risk for cardiovascular-related hospitalizations and sudden cardiac death [1–4]. However, the actual burden of hyperkalaemia, the rates of its recurrence and seasonality in its variation still remain unclear. METHOD Between June 2020 and May 2021, 1786 mid-week predialysis serum potassium (sK) measurements were retrospectively recorded from 149 patients receiving thrice-weekly haemodialysis in a single-centre in Thessaloniki, Greece. The prevalence, recurrence and seasonal variation of hyperkalaemia were assessed using three prespecified sK thresholds (≥5.1, ≥5.5 and ≥ 6.0 mmol/L). RESULTS At baseline (June 2020), 60.4%, 42.2% and 13.4% of patients had sK levels ≥ 5.1, ≥5.5 and ≥ 6.0 mmol/L, respectively. At any time-point during the 1-year-long follow-up, 85.2%, 69.8% and 38.9% of patients experienced at least 1 hyperkalaemic episode at the sK threshold of ≥ 5.1, ≥5.5 and ≥ 6.0 mmol/L, respectively. Of the 104 patients experiencing an initial sK elevation ≥ 5.5 mmol/L, hyperkalaemia at the same threshold reoccurred in 60.6% at month-1, in 47.1% at month-2 and in 46.1% at month-3 of follow-up. Seasonal variation was also observed, with the prevalence of hyperkalaemia to be significantly higher in summer. In multivariate logistic regression analysis, shorter delivered haemodialysis < 4 h/session {odds ratio (OR): 2.568; [95% confidence interval (95% CI): 1.045–6.313]} and the use of a high versus a low K concentration in the dialysate (OR: 14.646; 95% CI: 2.727–78.647) were the two factors that were associated with a significantly higher odds of hyperkalaemia at any time-point of the follow-up period. CONCLUSION The present study shows that among patients receiving conventional thrice-weekly haemodialysis, the rates of hyperkalaemia prevalence and recurrence are very high, reflecting the large unmet need to identify more effective potassium-lowering therapeutic interventions in this high-risk population.

MO666INVESTIGATIONS INTO DIFFERENCES AND SIMILARITIES BETWEEN SHORT DAILY HIGH-FLUX HEMODIALYSIS AND SHORT DAILY ON-LINE HEMODIAFILTRATION

Abstract Background and Aims Short daily hemodialysis (SDHD) has improved outcomes observed in conventional thrice-weekly hemodialysis (CHD). Analogously, short daily hemodiafiltration (SDHDF) has also improved outcomes observed in conventional thrice-weekly hemodiafiltration (CHDF). Furthermore, while high-volume CHDF has been proclaimed to be superior to CHD, there have been no studies comparing SDHDF to SDHD. We performed a comparison of clinical, laboratory, echocardiographic and quality of life features in dialysis patients treated by SDHD or SDHDF. Method Twelve patients (mean age 60.8±15.4 years; 7 males; AVF 7, AVG 1, Catheter 4) on regular in-center SDHD program were studied in a longitudinal, prospective, non-randomized, single-subject A-B-A design comparing high-flux SDHD to post-dilution on-line SDHDF. Patients had been for at least 6 months on SDHD (105-150min, 6x/week; SDHD1) and were clinically stable before conversion to SDHDF (105-150min, 6x/week, mean total convective volume of 63.57±5.44 L per week) for 6 months. Following that, all patients were switched back to SDHD for another 6 months (SDHD2). Data were collected at the end of each period. Dialysis parameters throughout the study were matched and set as follows: high-flux polysulfone dialyzers (BBraun Xevonta Hi 23®), blood flow 300–350 mL/min, dialysate flow 500 mL/min and ultra-purified water (Aquaboss heat disinfection osmosis). The results were expressed as mean ± standard deviation. Each patient served as his/her own control. Repeated measures analysis of variance (ANOVA) were used. Results Slightly higher predialysis mean arterial pressure (MAP) levels were observed during SDHDF (102.51±11.28 mmHg) compared to SDHD1 (MAP 95.5±9.82 mmHg, p<0.01) or to SDHD2 (97.61±11.19 mmHg, p=0.03), without significant differences in intradialytic blood pressure variability. Similarly, there was an increase in predialysis hemoglobin levels (Hb) during SDHDF (Hb 12.39±1.2 g/dL), compared to SDHD1 (Hb 11.30±1.09 g/dL, p=0.02) or to SDHD2 (Hb 11.23±1.84 g/dL, p<0.01), although there were no significant differences in erythropoietin-stimulating agent or iron supplementation weekly doses, transferrin saturation rates or ferritin levels. Solute kinetics measurements showed higher myoglobin clearance during SDHDF (45.95±11.0 mL/min) compared to SDHD1 (20.11±5.2 mL/min, p<0.01) or to SDHD2 (21.39±3.55 mL/min, p<0.01). Likewise, there was a slight increase in β2-microglobulin removal in SDHDF (64.92±10.4 mL/min) compared to SDHD1 (59.78±17.0 mL/min, p<0.01) or to SDHD1 (53.01±7.71 mL/min, p<0.01), whereas there were no significant differences in urea and creatinine clearances. On the other hand, predialysis osteometabolic (serum PTH, calcium, phosphate, alkaline phosphatase, sodium, potassium, glucose and glycated hemoglobin), inflammatory (serum c-reactive protein and interleukin-6) or nutritional (serum albumin, total protein and lipid profile) parameters did not change significantly during the study. Left ventricular mass index, left atrial volume index and global longitudinal strain, assessed by echocardiography at the end of all 3 periods, were similar, as well as brain natriuretic peptide and homocysteine serum levels. Additionally, there were no significant changes in any quality of life features evaluated by Kidney Disease Quality of Life-Short Form, or symptoms assessed by Edmonton Symptom Assessment System Revised Renal, throughout the full course of the study. Conclusion In spite of mild increase of predialysis mean arterial pressure and hemoglobin levels along with greater removal of middle molecular weight solutes, no others clinical, laboratory, echocardiographic or quality of life findings differed significantly during the three periods. Together, these data do not provide evidence of clinically meaningful benefit from on-line hemodiafiltration over high-flux hemodialysis, both performed six times a week.

Protection of Residual Renal Function and Nutritional Treatment: First Step Strategy for Reduction of Uremic Toxins in End-Stage Kidney Disease Patients.

The retention of uremic toxins and their pathological effects occurs in the advanced phases of chronic kidney disease (CKD), mainly in stage 5, when the implementation of conventional thrice-weekly hemodialysis is the prevalent and life-saving treatment. However, the start of hemodialysis is associated with both an acceleration of the loss of residual kidney function (RKF) and the shift to an increased intake of proteins, which are precursors of uremic toxins. In this phase, hemodialysis treatment is the only way to remove toxins from the body, but it can be largely inefficient in the case of high molecular weight and/or protein-bound molecules. Instead, even very low levels of RKF are crucial for uremic toxins excretion, which in most cases are protein-derived waste products generated by the intestinal microbiota. Protection of RKF can be obtained even in patients with end-stage kidney disease (ESKD) by a gradual and soft shift to kidney replacement therapy (KRT), for example by combining a once-a-week hemodialysis program with a low or very low-protein diet on the extra-dialysis days. This approach could represent a tailored strategy aimed at limiting the retention of both inorganic and organic toxins. In this paper, we discuss the combination of upstream (i.e., reduced production) and downstream (i.e., increased removal) strategies to reduce the concentration of uremic toxins in patients with ESKD during the transition phase from pure conservative management to full hemodialysis treatment.

Comparison between incremental and thrice-weekly haemodialysis: Systematic review and meta-analysis.

Incremental haemodialysis (HD) regimen has recently gained attention. However, its efficacy and safety, compared with conventional thrice-weekly HD, are controversial and previous research results are not convincing. We sought to conduct a meta-analysis to evaluate the benefits and limitations of incremental HD regimen in patients with end-stage renal disease. We searched PubMed, Embase, and the Cochrane Central Register databases for controlled trials published until January 2017. Outcomes of interest included baseline patient characteristics, mortality risk, renal function, urine volume, laboratory values, and hospitalization rate. Overall, 16 studies (n = 252 330), including 15 observational studies and 1 cross-sectional study, were included. Incremental HD reduced mortality risk, compared with conventional HD (risk ratio [RR], 0.797; 95% confidence interval [CI], 0.731-0.870; P < 0.001; I2 = 0%). Renal function (standardized mean difference [SMD] = 0.677, 95% CI: 0.035 to 1.318, P = 0.039; I2 = 92.7%) and urine volume (weighted mean difference [WMD] = 333.37, 95% CI: 86.81 to 579.93, P = 0.008; I2 = 92.7%) were also better preserved in patients on incremental HD. Other clinical outcomes, including serum levels of calcium, phosphate, albumin, haemoglobin, and hospitalization rate, were similar between groups. An incremental therapeutic approach as a beginning haemodialysis regimen is associated with lower mortality and better preservation of greater residual renal function.

Volume of urea cleared as a therapy dosing guide for more frequent hemodialysis.

With dialysis delivery systems that operate at low dialysate flow rates, prescriptions for more frequent hemodialysis (HD) employ dialysate volume as the primary parameter for small solute removal rather than blood-side urea dialyzer clearance (K). Such delivery systems, however, yield dialysate concentrations that almost completely saturate with blood (water), suggesting that the volume of urea cleared (the product of K and treatment time or Kt) can be readily estimated from the prescribed dialysate volume to target small solute removal. Methods For more frequent HD, we examined the volume of urea cleared per treatment required to achieve a minimal dose of small solute removal, comparing results based on body surface area (BSA) with those based on KDOQI clinical practice guidelines, that is, a weekly stdKt/V of 2.1. Estimates of the target volume of urea cleared were calculated for 4, 5, and 6 treatments per week, and compared for patients with different anthropometric estimates of total body water volume (Vant ). BSA was assumed proportional to Vant0.8 , and residual kidney function was neglected. Findings Whether based on BSA or weekly stdKt/V of 2.1, the target volume of urea cleared per treatment required to achieve a minimal dose of small solute removal was lower at higher treatment frequency. As with conventional thrice-weekly HD, target volumes of urea cleared for more frequent HD based on BSA were larger for patients with small Vant and smaller for patients with large Vant than those based on a weekly stdKt/V of 2.1. Discussion Prescription of more frequent HD using the volume of urea cleared per treatment, calculated from the prescribed dialysate volume, is simple in principle and can be readily implemented in clinical practice when using dialysis delivery systems that operate at low dialysate flow rates. Other aspects of dialysis adequacy require additional consideration.

Thyroid function in end stage renal disease and effects of frequent hemodialysis.

End-stage renal disease (ESRD) is associated with perturbations in thyroid hormone concentrations and an increased prevalence of hypothyroidism. Few studies have examined the effects of hemodialysis dose or frequency on endogenous thyroid function. Within the Frequent Hemodialysis Network (FHN) trials, we examined the prevalence of hypothyroidism in patients with ESRD. Among those with endogenous thyroid function (without overt hyper/hypothyroidism or thyroid hormone supplementation), we examined the association of thyroid hormone concentration with multiple parameters of self-reported health status, and physical and cognitive performance, and the effects of hemodialysis frequency on serum thyroid stimulating hormone (TSH), free thyroxine (FT4), and free tri-iodothyronine (FT3) levels. Conventional thrice-weekly hemodialysis was compared to in-center (6 d/wk) hemodialysis (Daily Trial) and Nocturnal (6 nights/wk) home hemodialysis (Nocturnal Trial) over 12 months. Among 226 FHN Trial participants, the prevalence of hypothyroidism was 11% based on thyroid hormone treatment and/or serum TSH ≥8 mIU/mL. Among the remaining 195 participants (147 Daily, 48 Nocturnal) with endogenous thyroid function, TSH concentrations were modestly (directly) correlated with age (r = 0.16, P = 0.03) but not dialysis vintage. Circulating thyroid hormone levels were not associated with parameters of health status or physical and cognitive performance. Furthermore, frequent in-center and nocturnal hemodialysis did not significantly change (baseline to month 12) TSH, FT4, or FT3 concentrations in patients with endogenous thyroid function. Among patients receiving hemodialysis without overt hyper/hypothyroidism or thyroid hormone treatment, thyroid indices were not associated with multiple measures of health status and were not significantly altered with increased dialysis frequency.

Incremental Hemodialysis: The University of California Irvine Experience.

Incremental hemodialysis has been examined as a viable hemodialysis regimen for selected end-stage renal disease (ESRD) patients. Preservation of residual kidney function (RKF) has been the driving impetus for this approach given its benefits upon the survival and quality of life of dialysis patients. While clinical practice guidelines recommend an incremental start of dialysis in peritoneal dialysis patients with substantial RKF, there remains little guidance with respect to incremental hemodialysis as an initial renal replacement therapy regimen. Indeed, several large population-based studies suggest that incremental twice-weekly vs. conventional thrice-weekly hemodialysis has favorable impact upon RKF trajectory and survival among patients with adequate renal urea clearance and/or urine output. In this report, we describe a case series of 13 ambulatory incident ESRD patients enrolled in a university-based center's Incremental Hemodialysis Program over the period of January 2015 to August 2016 and followed through December 2016. Among five patients who maintained a twice-weekly hemodialysis schedule vs. eight patients who transitioned to thrice-weekly hemodialysis, we describe and compare patients' longitudinal case-mix, laboratory, and dialysis treatment characteristics over time. The University of California Irvine Experience is the first systemically examined twice-weekly hemodialysis practice in North America. While future studies are needed to refine the optimal approaches and the ideal patient population for implementation of incremental hemodialysis, our case-series serves as a first report of this innovative management strategy among incident ESRD patients with substantial RKF, and a template for implementation of this regimen.

Revisiting the Middle Molecule Hypothesis of Uremic Toxicity: A Systematic Review of Beta 2 Microglobulin Population Kinetics and Large Scale Modeling of Hemodialysis Trials In Silico.

BackgroundBeta-2 Microglobulin (β2M) is a prototypical “middle molecule” uremic toxin that has been associated with a higher risk of death in hemodialysis patients. A quantitative description of the relative importance of factors determining β2M concentrations among patients with impaired kidney function is currently lacking.MethodsHerein we undertook a systematic review of existing studies reporting patient level data concerning generation, elimination and distribution of β2M in order to develop a population model of β2M kinetics. We used this model and previously determined relationships between predialysis β2M concentration and survival, to simulate the population distribution of predialysis β2M and the associated relative risk (RR) of death in patients receiving conventional thrice-weekly hemodialysis with low flux (LF) and high flux (HF) dialyzers, short (SD) and long daily (LD) HF hemodialysis sessions and on-line hemodiafiltration at different levels of residual renal function (RRF).ResultsWe identified 9 studies of 106 individuals and 156 evaluations of or more compartmental kinetic parameters of β2M. These studies used a variety of experimental methods to determine β2M kinetics ranging from isotopic dilution to profiling of intra/inter dialytic concentration changes. Most of the patients (74/106) were on dialysis with minimal RRF, thus facilitating the estimation of non-renal elimination kinetics of β2M. In large scale (N = 10000) simulations of individuals drawn from the population of β2M kinetic parameters, we found that, higher dialytic removal materially affects β2M exposures only when RRF (renal clearance of β2M) was below 2 ml/min. In patients initiating conventional HF hemodialysis, total loss of RRF was predicted to be associated with a RR of death of more than 20%. Hemodiafiltration and daily dialysis may decrease the high risk of death of anuric patients by 10% relative to conventional, thrice weekly HF dialysis. Only daily long sessions of hemodialysis consistently reduced mortality risk between 7–19% across the range of β2M generation rate.ConclusionsPreservation of RRF should be considered one of the therapeutic goals of hemodialysis practice. Randomized controlled trials of novel dialysis modalities may require large sample sizes to detect an effect on clinical outcomes even if they enroll anuric patients. The developed population model for β2M may allow personalization of hemodialysis prescription and/or facilitate the design of such studies by identifying patients with higher β2M generation rate.

Cognitive changes associated with switching to frequent nocturnal hemodialysis or renal transplantation.

BackgroundIt is uncertain whether switching to frequent nocturnal hemodialysis improves cognitive function in well-dialyzed patients and how this compares to patients who receive a kidney transplant.MethodsWe conducted a multicenter observational study with longitudinal follow-up of the effect on cognitive performance of switching dialysis treatment modality from conventional thrice-weekly hemodialysis to frequent nocturnal hemodialysis, a functioning renal transplant or remaining on thrice-weekly conventional hemodialysis. Neuropsychological tests of memory, attention, psychomotor processing speed, executive function and fluency as well as measures of solute clearance were performed at baseline and again after switching modality. The change in cognitive performance measured by neuropsychological tests assessing multiple cognitive domains at baseline, 4 and 12 months after switching dialysis modality were analyzed using a linear mixed model.ResultsSeventy-seven patients were enrolled; 21 of these 77 patients were recruited from the randomized Frequent Hemodialysis Network (FHN) Nocturnal Trial. Of these, 18 patients started frequent nocturnal hemodialysis, 28 patients received a kidney transplant and 31 patients remained on conventional thrice-weekly hemodialysis. Forty-eight patients (62 %) returned for the 12-month follow-up. Despite a significant improvement in solute clearance, 12 months treatment with frequent nocturnal hemodialysis was not associated with substantial improvement in cognitive performance. By contrast, renal transplantation, which led to near normalization of solute clearance was associated with clinically relevant and significant improvements in verbal learning and memory with a trend towards improvements in psychomotor processing speed. Cognitive performance in patients on conventional hemodialysis remained stable with the exception of an improvement in psychomotor processing speed and a decline in verbal fluency.ConclusionsIn patients on conventional thrice-weekly hemodialysis, receiving a functioning renal transplant was associated with improvement in auditory-verbal memory and psychomotor processing speed, which was not observed after 12 months of frequent nocturnal hemodialysis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-016-0223-9) contains supplementary material, which is available to authorized users.

Let us give twice-weekly hemodialysis a chance: revisiting the taboo.

Let us give twice-weekly hemodialysis a chance: revisiting the taboo.

Frequent Hemodialysis: A Critical Review

Conventional, thrice-weekly hemodialysis (CHD) is the most commonly prescribed dialysis regimen. Despite widespread acceptance of CHD, long-term analyses of registry data have revealed an increased risk for mortality during the long 2-day interdialytic interval of thrice-weekly therapies. High mortality rates during this period suggest that there may be a role for more frequent HD in improving patient outcomes and survival through elimination of the long interdialytic period. Several regimens have been investigated including: short, daily HD, frequent nocturnal HD, and alternate-day HD. In this review, we provide an in-depth summary of current data comparing the effects of frequent and CHD modalities on survival, hospitalizations, vascular access complications, burden of therapy, quality of life, residual renal function, cardiovascular parameters, bone mineral metabolism, and anemia. Limitations of the data as well as the role of frequent dialysis in clinical practice are also discussed.

Survival comparison between intensive hemodialysis and transplantation in the context of the existing literature surrounding nocturnal and short-daily hemodialysis

Our contemporary paradigms of nocturnal and short-daily hemodialysis (NHD and SDHD) have their origins in the earliest era of dialysis care for end-stage renal disease. However, these therapies have received considerably more attention in recent years owing to an increasing body of literature, suggesting a myriad of benefits attributable to these intensive dialysis regimens compared with conventional thrice-weekly hemodialysis. Analyses suggest a survival benefit for NHD and SDHD versus traditional hemodialysis prescriptions, and it is in this context that survival comparisons between intensive dialysis and transplantation must be considered. This literature and its limitations are reviewed here.

A Difference Between Day and Night: Protein Intake Improves After the Transition From Conventional to Frequent Nocturnal Home Hemodialysis

Malnutrition is an important cause of the excessive morbidity and mortality rate of dialysis patients. Frequent nocturnal home hemodialysis (NHHD) has many benefits compared with conventional thrice-weekly hemodialysis (CHD), due to the virtual absence of dietary restrictions and a much higher overall dialysis efficiency. In this observational study, we investigated whether these benefits of NHHD translate into an improved nutritional intake, with a special emphasis on protein intake. We prospectively assessed the effect of the transition of CHD to NHHD on nutritional intake (5-day dietary intake journal), normalized protein catabolic rate, and anthropometric parameters in 15 consecutive patients who started NHHD in our center between 2004 and 2009 and completed at least 8 months of follow-up. Data were collected before the transition from CHD to NHHD and 4 and 8 months after the transition. Protein intake, as measured by both dietary intake journal and normalized protein catabolic rate, increased significantly after the transition from CHD to NHHD. Accordingly, phosphate intake increased significantly; however, serum phosphate levels did not increase, despite negligible phosphate binder use during NHHD. Body mass index and upper arm muscle circumference did not change significantly. The transition from CHD to NHHD has a positive effect on nutritional intake, in particular, protein intake. NHHD should be considered in malnourished patients on CHD.

Frequent Hemodialysis Schedules Are Associated with Reduced Levels of Dialysis-induced Cardiac Injury (Myocardial Stunning)

Recurrent hemodialysis (HD)-induced ischemic cardiac injury (myocardial stunning) is common and associated with high ultrafiltration (UF) requirements, intradialytic hypotension, long-term loss of systolic function, increased likelihood of cardiovascular events, and death. More frequent HD regimens are associated with lower UF requirements and improved hemodynamic tolerability, improved cardiovascular outcomes, and reduced mortality compared with conventional thrice-weekly HD. This study investigated the hypothesis that modification of UF volume and rate with more frequent HD therapies would abrogate dialysis-induced myocardial stunning. A cross-sectional study of 46 patients established on hemodialysis >3 months compared four groups receiving the current range of quotidian therapies: conventional thrice-weekly HD (CHD3); more-frequent HD five to six times/week in a center (CSD) and at home (HSD); and home nocturnal HD (HN). Serial echocardiography quantitatively assessed regional systolic function to identify intradialytic left ventricular regional wall motion abnormalities (RWMAs). Cardiac troponin T (cTnT), N-terminal prohormone brain natriuretic peptide (NT-proBNP), and inflammatory markers were quantified. More frequent HD regimens were associated with lower UF volumes and rates compared with CHD3. Intradialytic fall in systolic BP was reduced in CSD and HSD groups and abolished in HN group. Mean RWMAs per patient reduced with increasing dialysis intensity (CHD3 > CSD > HSD > HN). Home-based groups demonstrated lower high-sensitivity C-reative protein levels, with trends to lower cTnT and NT-proBNP levels in the more frequent groups. Frequent HD regimes are associated with less dialysis-induced myocardial stunning compared with conventional HD. This may contribute to improved outcomes associated with frequent HD therapies.

Conversion from conventional in-centre thrice-weekly haemodialysis to short daily home haemodialysis ameliorates uremia-associated clinical parameters

Under physiological conditions, kidneys work continuously, 168 h/week. In contrast, patients with end-stage renal disease are usually dialysed only 12 h/week. Even if considered adequate by current Kt/V-based dose estimates, this unphysiological dose is associated with an unacceptable annual mortality rate of 10-20%. Increasing dialysis dose might ameliorate this mortality rate. Eleven patients were switched from their conventional haemodialysis (cHD, 3 × 4 h/week) to an intensified short daily home haemodialysis regimen (sdhHD, 6 × 3 h/week) and followed up for 12 months. Different parameters were evaluated before treatment conversion and quarterly during follow-up [i.e. dialysis efficacy, mean arterial pressure (MAP), antihypertensive drug score, haemoglobin, transferrin saturation, ferritin, dose of erythropoiesis-stimulating agents (ESA), iron requirement, parameters of nutrition (body weight, albumin, protein), C-reactive protein, calcium-phosphate product, alkaline phosphatase (AP), intact parathyroid hormone (iPTH) and amount of phosphate-binding pharmacotherapy]. HD efficacy as assessed by cumulative blood volume increased after dialysis intensification (P < 0.01). The pre- and post-dialytic MAP declined during the study period (P < 0.0001), while antihypertensive drugs could be reduced (P = 0.02). Haemoglobin levels improved (P < 0.0001). Additionally, the need for ESAs fell under intensified sdhHD (P = 0.008). Nutritional status improved [albumin, P = 0.03; total serum protein, P = 0.02; 'dry' body weight (BW) and body mass index (BMI) (both P < 0.001)]. The calcium-phosphate product declined (P < 0.01), without changes in the dose of phosphate binders. Conversion from conventional in-centre to short daily home HD leads to an improvement in numerous dialysis-associated metabolic variables and thus represents an attractive treatment modality for selected patients.

Home hemodialysis: Present state of the evidence

disappointing results suggested that the high mortality associated with hemodialysis could not be impacted upon with relatively small increases in solute clearance. It also further questioned the rationale of focusing on Kt/V as a measure of dialysis adequacy. The mortality rate for hemodialysis patients in the U.S. is high at approximately 24.4 deaths/100 patient-years.4 The high mortality rate has persisted despite progressive increases in Kt/V over the past two decades, from 1.11 in 1991 to 1.52 in 2002.5 In addition, despite this increase in Kt/V, the complications of hypertension,6 malnutrition,7 congestive heart failure,8 and bone and mineral disorders9 have remained unacceptably high. These outcome data clearly indicate that dialysis adequacy cannot be simply measured in terms of Kt/V. Given these persistently poor outcomes

Review: Differences in prescription between conventional and alternative haemodialysis

There is growing interest worldwide in the beneficial effects of increasing the frequency and/or time of haemodialysis (HD) sessions. Alternative HD regimens to incorporate these changes, also called 'quotidian' HD schedules, likely offer advantages over conventional thrice-weekly HD. Alternative regimens include short-daily HD (typically performed 1.5-3 h, 5-7 days per week) and nocturnal HD (typically 6-8 h, 3-7 nights per week). Both regimens can be performed at home or in the hospital setting, although in Australia and New Zealand the predominant alternative regimen is nocturnal HD at home. Dialysis prescriptions for alternative schedules vary in many aspects when compared with conventional HD and this review describes differences in dialysate concentrations, blood and dialysate flow rates, ultrafiltration rates, vascular access issues and adequacy of HD between the different HD modalities. An international quotidian dialysis registry has also recently been created to capture observational data on patients receiving alternative HD regimens and provides further information on dialysis prescriptions for these therapies.

Innovation in the Treatment of Uremia: Proceedings from the Cleveland Clinic Workshop: Bottom‐Up Nanotechnology: The Human Nephron Filter

Over one million patients worldwide have end-stage renal disease and require dialysis or kidney transplantation. Despite the availability of these forms of renal replacement therapy for nearly four decades, mortality and morbidity are high and patients often have a poor quality of life. We have developed a human nephron filter (HNF) utilizing bottom-up nanotechnology that would eventually make feasible a continuously functioning, wearable or implantable artificial kidney. The device consists of two membranes operating in series within one device cartridge. The first membrane mimics the function of the glomerulus, using convective transport to generate a plasma ultra filtrate, which contains all solutes approaching the molecular weight of albumin. The second membrane mimics the function of the renal tubules, selectively reclaiming designated solutes to maintain body homeostasis. No dialysis solution is used in this device. The HNF has been computer modeled, and operating 12 hour per day, 7 days per week the HNF provides the equivalent of 30 ml/min glomerular filtration rate (compared to half that amount for conventional thrice-weekly hemodialysis). The HNF system, by eliminating dialysate and utilizing a novel membrane system created through applied nanotechnology, represents a breakthrough in renal replacement therapy based on the functioning of native kidneys. The enhanced solute removal and wearable design should substantially improve patient outcomes and quality of life.