Daily Hemodialysis Research Articles

The role of short daily hemodialysis in the control of hyperphosphatemia, secondary hyperparathyroidism and anemia

Hyperphosphatemia, secondary hyperparathyroidism (SHPT) and anemia are common secondary complications in hemodialysis patients with end-stage renal disease (ESRD). Compared with conventional hemodialysis (CHD), short daily hemodialysis (sDHD) has been found to be more effective in patients with ESRD. The objective of this study was to determine whether sDHD could improve hyperphosphatemia, SHPT and anemia in patients with ESRD. Twenty-seven patients (11 women and 16 men, 46.8 ± 13.4 years old) were switched from CHD to sDHD. All hematologic parameters were measured prior to the switch (baseline), at 3 months after the switch (sDHD(1)) and at 6 months after the switch (sDHD(2)). The serum phosphate decreased from 2.54 ± 0.32 mmol/L at baseline to 2.15 ± 0.36 mmol/L (p < 0.001) at sDHD(1) and 1.97 ± 0.33 mmol/L (p < 0.001) at sDHD(2). Calcium-phosphate product decreased from 5.18 ± 1.24 mmol(2)/L(2) at baseline to 4.20 ± 0.71 mmol(2)/L(2) (p < 0.001) at sDHD(1) and 4.02 ± 0.83 mmol(2)/L(2) (p < 0.001) at sDHD(2). The serum PTH levels decreased from 223.9 ± 124.7 pmol/L at baseline to 196.3 ± 101.3 pmol/L (p < 0.05) at sDHD(2). The hemoglobin concentration increased significantly from CHD to sDHD. However, the requirement for erythropoietin (EPO) dose decreased from 6847.8 ± 1057.3 u/week at baseline to 5869.6 ± 1094.6 u/week (p < 0.05) at sDHD(2). sDHD may decrease serum phosphate, calcium-phosphate product and PTH, increase hemoglobin levels and decrease exogenous EPO dose requirements compared with CHD in hemodialysis patients.

Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis

Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.

The efficacy of incretin therapy in patients with type 2 diabetes undergoing hemodialysis

BackgroundAlthough incretin therapy is clinically available in patients with type 2 diabetes undergoing hemodialysis, no study has yet examined whether incretin therapy is capable of maintaining glycemic control in this group of patients when switched from insulin therapy. In this study, we examined the efficacy of incretin therapy in patients with insulin-treated type 2 diabetes undergoing hemodialysis.MethodsTen type 2 diabetic patients undergoing hemodialysis received daily 0.3 mg liraglutide, 50 mg vildagliptin, and 6.25 mg alogliptin switched from insulin therapy on both the day of hemodialysis and the non-hemodialysis day. Blood glucose level was monitored by continuous glucose monitoring. After blood glucose control by insulin, patients were treated with three types of incretin therapy in a randomized crossover manner, with continuous glucose monitoring performed for each treatment.ResultsDuring treatment with incretin therapies, severe hyperglycemia and ketosis were not observed in any patients. Maximum blood glucose and mean blood glucose on the day of hemodialysis were significantly lower after treatment with liraglutide compared with treatment with alogliptin (p < 0.05), but not with vildagliptin. The standard deviation value, a marker of glucose fluctuation, on the non-hemodialysis day was significantly lower after treatment with liraglutide compared with treatment with insulin and alogliptin (p < 0.05), but not with vildagliptin. Furthermore, the duration of hyperglycemia was significantly shorter after treatment with liraglutide on both the hemodialysis and non-hemodialysis days compared with treatment with alogliptin (p < 0.05), but not with vildagliptin.ConclusionsThe data presented here suggest that patients with type 2 diabetes undergoing hemodialysis and insulin therapy could be treated with incretin therapy in some cases.

A Safe and Easy Introduction of Darbepoetin-Alpha in Patients Receiving Maintenance Hemodialysis and Epoetin Monotherapy: A “Half-and-Half” Combination Therapy

BackgroundIn hemodialysis (HD) patients requiring anemia management, the 3-fold longer terminal half-life (25.3 hours) of darbepoetin-alpha (DA) results in reduced dose frequency when compared with recombinant human erythropoietin (EPO) -alpha or -beta by intravenous administration (8.5 hours). However, this might become a disadvantage in the face of rapid withdrawal of the drug against hemoglobin (Hb) overshoot and/or cycling. ObjectiveA “half-and-half” combination therapy of DA and EPO was used to avoid a possible Hb overshoot due to the full conversion from EPO to DA. MethodsThirty-two stable patients receiving HD (13 men, 19 women) and EPO monotherapy were enrolled and prospectively followed for 9 months. The mean (SD) patient age was 63.2 (11.3) years. The HD duration was 10.7 (8.2) years. The DA doses (in micrograms) of 1/200 of halves of previous weekly EPO doses (in international units) were given intravenously on the second HD day of a week. The remaining half doses of previous weekly EPO doses were dividedly administered intravenously on the first and the third HD days of the week. The target Hb was 11 g/dL. ResultsThe “half-and-half” combination with DA and EPO resulted in no episodes of Hb overshoot. The Hb values did not exceed 13 g/dL throughout the follow-up period. The mean (SD) dose of 3984 (2175) IU/wk EPO was converted to a combination of 1688 (894) IU/wk EPO and 13.4 (7.9) μg/wk DA at baseline. Thereafter, the mean (SD) doses became 304 (656) IU/wk EPO and 16.0 (8.4) μg/wk DA at 3 months, and 532 (912) IU/wk and 15.8 (9.0) μg/wk, respectively, at 9 months. The total combination doses of DA/EPO (as EPO equivalents) were significantly reduced to 80% to 84% of the original EPO doses after 2 months of introduction of the DA/EPO combination. ConclusionsA “half-and-half” combination therapy may be a safe and easy method to merge DA into EPO monotherapy without Hb overshoot or dramatic cycling.

Risk of Vascular Access Complications with Frequent Hemodialysis

Frequent hemodialysis requires using the vascular access more often than with conventional hemodialysis, but whether this increases the risk for access-related complications is unknown. In two separate trials, we randomly assigned 245 patients to receive in-center daily hemodialysis (6 days per week) or conventional hemodialysis (3 days per week) and 87 patients to receive home nocturnal hemodialysis (6 nights per week) or conventional hemodialysis, for 12 months. The primary vascular access outcome was time to first access event (repair, loss, or access-related hospitalization). Secondary outcomes were time to all repairs and time to all losses. In the Daily Trial, 77 (31%) of 245 patients had a primary outcome event: 33 repairs and 15 losses in the daily group and 17 repairs, 11 losses, and 1 hospitalization in the conventional group. Overall, the risk for a first access event was 76% higher with daily hemodialysis than with conventional hemodialysis (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.11-2.79; P=0.017); among the 198 patients with an arteriovenous (AV) access at randomization, the risk was 90% higher with daily hemodialysis (HR, 1.90; 95% CI, 1.11-3.25; P=0.02). Daily hemodialysis patients had significantly more total AV access repairs than conventional hemodialysis patients (P=0.011), with 55% of all repairs involving thrombectomy or surgical revision. Losses of AV access did not differ between groups (P=0.58). We observed similar trends in the Nocturnal Trial, although the results were not statistically significant. In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.

A multinational cohort study of in-center daily hemodialysis and patient survival

Increasing hemodialysis frequency from three to six times per week improves left-ventricular mass and health-related quality of life; however, effects on survival remain uncertain. To study this, we identified 556 patients in the International Quotidian Dialysis Registry who received daily hemodialysis (more than five times per week) between 2001 and 2010. Using propensity score-based matching, we matched 318 of these patients to 575 contemporaneous patients receiving conventional (three times weekly) hemodialysis in the Dialysis Outcomes and Practice Patterns Study. All patients had session times of <5 h, and received dialysis in the clinic or hospital setting. Mortality rates between groups were compared using Cox proportional hazards regression. Mean dialysis frequency in the daily group was 5.8 sessions per week. Mean weekly treatment time was 15.7 h for daily and 11.9 h for conventional patients. During 1382 patient-years of follow-up, 170 patients died. Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous studies, we found that in-center daily hemodialysis was not associated with any mortality benefit. Thus, decisions to undertake daily hemodialysis should be based on quality-of-life improvements, rather than on claims of improved survival.

Survival by Time of Day of Hemodialysis in Korean Patients: A Single Center Study

Survival by Time of Day of Hemodialysis in Korean Patients: A Single Center Study

Survival by Time of Day of Hemodialysis in Korean Patients: A Single Center Study

Background: Patients with end-stage renal disease (ESRD) typically undergo hemodialysis (HD) during the morning or afternoon, with time of treatment generally based on space availability or patient preference. No studies have investigated variation in patient survival as a function of the time of day of dialysis in Korean HD patients. We investigated the association of patient HD treatment shift with continued survival, controlling for well-established HD-related mortality risk factors. Method: A 10-year (from January 1, 2001 to December 31, 2010) follow-up retrospective cohort study was conducted among 120 ESRD patients who underwent HD at Kosin University Gospel Hospital either during a morning shift (n = 60) or an afternoon shift (n = 60). A variable comparison was conducted using a Chi-square test and t-test for categorical and continuous variables, respectively. Life table analysis was used to compare survival rates in the two treatment groups. Results: The mean survival rate of the morning-shift HD patients and afternoon-shift HD patients were not statistically different (mean survival, 61.1 months vs. 48.2 months; P = 0.139). The unadjusted 5-year survival rate for patients on morning shift hemodialysis was 87.3% versus 86.4% for patients on afternoon shift hemodialysis (P = 0.704 by Wilcoxon test). Conclusions: The survival rates of morning-shift HD patients and afternoon-shift HD Research Article British Journal of Medicine & Medical Research, 3(1): 108-115, 2013 109 patients were not different. Results from this cohort study may warrant prospective observational studies and randomized clinical trials in Korean HD patients for whom the time of day at which HD is administered is systemically varied.

Gentamicin Dosing and Monitoring Challenges in End-Stage Renal Disease

The second leading cause of mortality in end-stage renal disease patients on intermittent hemodialysis is infection. Gentamicin is frequently used in this patient population to treat infections due to the convenience of dosing only on hemodialysis days. Dosing recommendations vary among the most commonly used drug information databases. Differences are found in recommendations for both dosing and monitoring. Conflicting information found in drug information databases and primary literature can cause confusion among clinicians regarding the best way to dose and monitor gentamicin in ESRD patients on hemodialysis. While current practice utilizes posthemodialysis gentamicin dosing, there is primary literature that introduces the concept of pre-dialysis dosing. Predialysis gentamicin dosing may result in favorable pharmacokinetic profile.

Renal anaemia treatment in haemodialysis patients in the Central and Eastern European countries in everyday clinical practice follow-up

BackgroundChronic kidney disease is almost always accompanied by anaemia. Erythropoietin-stimulating agents (ESA) can increase haemoglobin concentration and thus reduce the frequency of anaemia-related complications including the cardiovascular events.AimThe aim of the study was to collect prospective data on 12-month standard ESA therapy used in haemodialyzed patients in selected CEE countries as well as on cardiovascular complications, iron status and anaemia treatment.Patients and methodsFifty centres in 3 countries participated in the study. A group of 398 haemodialysed stable patients (M-231, F-167) aged 19–90 years (57.5 ± 14.7) on standard ESA therapy for chronic renal anaemia were recruited. Twelve-month prospective data on iron parameters, ESA therapy and cardiovascular events were collected. The use of iron, folic acid and blood transfusions were also assessed. Patient were divided into three groups according to ESA therapy start: group A—patients who received ESA after start of haemodialysis, group B—patients who received ESA within 3 months from the day of first haemodialysis and group C—patients who had received ESA more than 3 months before haemodialysis. Chi2 test for qualitative data and Kruskall–Wallis test for quantitative data with p < 0.05 were used in statistical analysis.ResultsAt prestudy period, the mean weekly dose of ESA in group C was statistically lower than in the remaining two groups (3,823 ± 3,169 vs. 5,276 ± 2,915 and 6,427 ± 3,441 units/week, p < 0.001), but during prospective phase of the study the doses did not differ among groups A, B and C. No major fluctuation of ESA administration schedule was observed during the study in the groups; however, at majority of visits, the mean frequency of ESA administration in group C was statistically higher than in groups A and B. At baseline visit, the haemoglobin concentration in group A patients (10.86 ± 1.34 g/dL) was slightly lower than in group B (11.26 ± 1.43 g/dL) and group C (10.98 ± 1.35 g/dL) (p = 0.025), but at subsequent visits these differences disappeared and mean haemoglobin concentration was stable around 11 g/dL. Ferritin concentration increased from 280 ± 241 at baseline to 506 ± 405 at month 12, and no important differences in the groups were observed. The other haematological parameters (haematocrit, iron concentration) remained stable during the entire study. The frequency of blood transfusion and total volume of blood in group C were lower than in groups A and B. During the prospective 12-month follow-up, 23 (5.8 %) of the patients died and 35 (8.8 %) were transplanted. No differences in death or transplantation rate were observed among groups A, B and C. The number of patients with adverse events, serious adverse events or drug-related adverse events in all groups was similar. In conclusion, ESA therapy increased haemoglobin concentration and no major differences in haematological parameters among the groups were observed during the entire study irrespective of early versus late start. Mortality, cardiovascular events or other adverse events were similar among the groups during the observation period; however, the limitation of the study is the sample size.

The relevance of dietary sodium in hemodialysis

Since the earliest days of hemodialysis, dietary sodium restriction has been recommended as a therapeutic means to mitigate problems of extracellular volume overload, hypertension and inter-dialytic weight gain. Recently, there has been a proliferation of human subjects' research examining the potential effects of dietary sodium curtailment. Herein we examine the available evidence with respect to the effects of dietary sodium restriction on clinically relevant endpoints among hemodialysis patients.

Modalities of hemodialysis: quality improvement.

Hemodialysis (HD) treatment had, over many years, improved the survival rate of patients with end-stage renal disease. However, standard or conventional HD prescription is far from being optimal in replacing the function of normal kidneys. Its unphysiologic clearance pattern and inability to remove all types and sizes of uremic toxins results in inter- and intra-dialysis complications and an unacceptably high rate of cardiovascular morbidity and mortality. Efficiency of HD can be improved by increasing blood and dialysate flow rates, dialyzer size and surface area and duration and frequency of dialysis sessions. Home HD, where short daily or long slow nocturnal HD sessions can conveniently be performed, provides an excellent option for quality of life improvement and reduction in morbidity and mortality. Recent innovations in the specifications of HD machines and improvement in dialysis membranes characteristics and water treatment technology paved the way for achieving quality HD. These advancements have resulted in efficient implementation of adsorption, diffusion and/or convection principles using adsorption HD, hemofiltration, hemodiafiltration (HDF) and online HDF modalities in order to achieve optimum HD. Implementation of these innovations resulted in better quality care achievements in clinical practice and reduction in morbidity and mortality rates among HD patients.

Vascular access outcomes with daily haemodialysis

Vascular access outcomes with daily haemodialysis

THE ANTICOAGULANT THERAPY OF HAEMODIALYSIS PATIENTS WITH ACUTE CORONARY SYNDROME

ObjectivesTo evaluate the effect of different dose of anticoagulants in haemodialysis patients with acute coronary syndrome (not including ST-elevate myocardial infarction).Methods28 patients with ACS (not including ST-elevate myocardial infarction) were...

Feasibility of oral arsenic trioxide treatment for acute promyelocytic leukemia during hemodialysis

Dear Editor, Arsenic trioxide (As2O3) is a standard medication for relapsed acute promyelocytic leukemia (APL). However, high blood arsenic levels lead to potentially fatal arrhythmias. As2O3 is renal-excreted and considered contraindicated in renal failure. A 42-year-old man was referred for treatment of APL in first relapse, presenting with pancytopenia, impaired renal function, and septicemia. He was treated with all-trans retinoic acid (ATRA, 45 mg/m2/day) and oral As2O3 (10 mg/day) [1]. Progressive renal function derangement developed, necessitating reduction of oral As2O3 to 5 mg/day. On the third day, the leukocyte count increased to 8.9 × 109/L, associated with bilateral pulmonary infiltrates. Features were consistent with the APL differentiation syndrome, which with the underlying septicemia led to anuric acute renal failure. ATRA was stopped. Idarubicin (6 mg/m2/day × 5), dexamethasone (12 mg/day × 7), and alternate daily hemodialysis were administered. Oral As2O3 at 5 mg was given after each hemodialysis and was stopped after 9 days. At 4 weeks, marrow examination confirmed complete remission. He remained anuric, and hemodialysis was continued. Oral As2O3 was re-commenced at 2 mg after each hemodialysis. Two months later, continuous ambulatory peritoneal dialysis (CAPD) was started. A maintenance regimen for APL, comprising oral As2O3 (5 mg/day) and ATRA (20 mg twice daily) [2, 3], given 2 weeks every 2 months, was administered. At 6-month follow-up, he remained in remission and was negative for the PML-RARA fusion gene characteristic of APL. No cardiac arrhythmias were observed at any time. Serum elemental arsenic levels were assayed by inductively coupled plasma mass spectrometry [3, 4], on blood samples sent for creatinine measurement. At 4 days, there was a sudden increase of arsenic levels, as the cellular and third-space compartments became saturated and anuria prevented arsenic excretion (Fig. 1a). The arsenic level peaked at 4,240 nmol/L, outside the therapeutic range of 500–2,000 nmol/L typical of oral As2O3. The commencement of hemodialysis and cessation of oral As2O3 resulted in a fall of arsenic levels parallel to those of creatinine. After oral As2O3 was re-commenced, arsenic levels gradually increased to the therapeutic range (Fig. 1b). As arsenic clearance in oral As2O3 therapy during CAPD had been documented previously [3], arsenic assays were not performed after peritoneal dialysis was started. Fig. 1 a Blood arsenic levels during the first 3 weeks of hemodialysis. A rapid surge of arsenic levels occurred on day 5, in parallel with a rise in creatinine and further renal function deterioration. Oral arsenic trioxide was stopped on day 9, resulting ... As2O3 is a key medication for patients with relapsed APL. Intravenous (i.v.) As2O3, used in most reports, may lead to lethal arrhythmias due to QT prolongation, which is directly proportional to blood arsenic levels [5]. Because i.v. As2O3 leads to a rapid surge of blood arsenic levels, arrhythmia related to QT prolongation is an important adverse effect. Oral As2O3 is slowly absorbed and results in lower blood arsenic levels. Its bioavailability, estimated by area-under-the-curve pharmacokinetically, is comparable to that of i.v. As2O3 [6]. Hence, oral As2O3 has the same efficacy, but little risk of arrhythmia [5]. In one previous report, blood arsenic levels after i.v. As2O3 were measured in an APL patient on hemodialysis [7]. The peak level was 6,450 nmol/L, a toxic level that led to termination of i.v. As2O3 therapy. It was concluded that i.v. As2O3 was contraindicated in renal failure [7]. In our case, the sudden increase in blood arsenic levels was related to an unanticipated acute renal failure. Timely cessation of oral As2O3 and institution of hemodialysis prevented further increases in arsenic levels. Subsequently, with careful dose adjustment and meticulous monitoring, oral As2O3 was safely administered during hemodialysis. The blood arsenic levels were also kept within the therapeutic range. We have also previously demonstrated the safety of oral As2O3 during CAPD. Therefore, patients on renal replacement therapy are still eligible for oral As2O3 treatment.

Long‐term effects of daily hemodialysis on vascular access outcomes: A prospective controlled study

Daily hemodialysis has been associated with surrogate markers of improved survival among hemodialysis patients. A potential disadvantage of daily hemodialysis is that frequent vascular access cannulations may affect long-term vascular access patency. The study design was a 4-year, nonrandomized, contemporary control, prospective study of 77 subjects in either 3-h daily hemodialysis (six 3-h dialysis treatments weekly; n = 26) or conventional dialysis (three 4-h dialysis treatments weekly; n = 51). Outcomes of interest were vascular access procedures (fistulagram, thrombectomy and access revision). Total access procedures (fistulagram, thrombectomy and access revision) were 543.2 (95% confidence interval [CI]: 432.9, 673.0) per 1000 person-years in the conventional dialysis group vs. 400.8 (95% CI: 270.2, 572.4) per 1000 person-years in the daily hemodialysis dialysis group (incidence rate ratio = 0.74 with 95% CI: from 0.40 to 1.36, P = 0.33), after adjusting for age, gender, diabetes status, serum phosphorus, hemoglobin level and erythropoietin dose, there was no significant differences in incidence rate of total access procedures (P-value > 0.05). There was no difference in time to first access revision between the daily dialysis and the conventional dialysis groups after adjustment for covariates (hazard ratio = 0.99 95% CI: 0.42, 2.36, P = 0.96). Daily hemodialysis is not associated with increased vascular access complications, or increased vascular access failure rates.

At-home short daily hemodialysis improves the long-term health-related quality of life

Patients with chronic kidney disease treated by in-center conventional hemodialysis (3 times per week) have significant impairments in health-related quality of life measures, which have been associated with increased morbidity and mortality. FREEDOM is an ongoing prospective cohort study measuring the potential benefits of at-home short daily (6 times per week) hemodialysis. In this interim report we examine the long-term effect of short daily hemodialysis on health-related quality of life, as measured by the SF-36 health survey. This was administered at baseline, 4 and 12 months after initiation of short daily hemodialysis to 291 participants (total cohort), of which 154 completed the 12-month follow-up (as-treated cohort). At the time of analysis, the mean age was 53 years, 66% were men, 58% had an AV fistula, 90% transitioned from in-center hemodialysis, and 45% had diabetes mellitus. In the total cohort analysis, both the physical- and mental-component summary scores improved over the 12-month period, as did all 8 individual domains of the SF-36. The as-treated cohort analysis showed similar improvements with the exception of the role-emotional domain. Significantly, in the as-treated cohort, the percentage of patients achieving a physical-component summary score at least equivalent to the general population more than doubled. Hence, at-home short daily hemodialysis is associated with long-term improvements in various physical and mental health-related quality of life measures.

Benefits of short daily home hemodialysis in the FREEDOM Study: is it about person, place, time, or treatment?

Many end-stage renal disease patients receive thrice-weekly hemodialysis (HD) and report impairments in health-related quality of life (HRQOL). Recent studies indicate that short daily HD may improve HRQOL. High-quality studies exploring the burdens and costs to patients, caregivers, and society are necessary before widespread adoption can be advocated. Further research exploring the mechanisms by which these benefits are realized is also important, as many patients are likely to opt out of short daily HD.

Tratamiento de la ira secundaria a mieloma múltiple con filtro de high cut-off

We report the case of a 56-year-old man who had been monitored in the Hematology Department since 2009 with a diagnosis of asymptomatic IgG λ multiple myeloma and cytogenic findings of poor prognosis (a P53 gene deletion).After several months under observation and without treatment, disease progression occurred with anemia (hemoglobin 9.8g/dL), renal failure (creatinine 2mg/dL) and increased urinary excretion of lambda light chains (10.8g/24h). Treatment with bortezomib/thalidomide/dexamethasone was initiated with no response. Subsequently, the kidney failure showed abrupt worsening (creatinine 8.8mg/dl) and consequently dialysis with a high cut-off filter (Theralite) was started. The Hematology Department decided to switch the treatment to lenalidomide.Treatment was started with daily hemodialysis for 6 days, followed by alternate days. After 53 days of treatment and 27 dialysis sessions, the level of free light chains decreased to 1,000mg/dl, and glomerular function was 26 cc/min. Dialysis with the HCO filter was then withdrawn. ConclusionThe HCO filter was effective in removing plasma free light chains and in treating the acute renal failure.

Patient experiences and preferences on short daily and nocturnal home hemodialysis

Quotidian/intensive hemodialysis (short daily and nocturnal) has variable effects on health-related quality of life (HRQOL) as measured by standard HRQOL tools. We sought to understand the perceived benefits and limitations of quotidian dialysis by interviewing patients who had switched from conventional to home quotidian dialysis. We used a qualitative, phenomenological approach to explore the perceived benefits of quotidian dialysis from 10 patients using either short daily or nocturnal hemodialysis at a tertiary health care center in London, Canada. The patients varied in gender, age, employment status, home support, physical capacity, primary cause of kidney disease, previous forms of renal replacement therapy, and level of education. Four major themes emerged: (1) improvement in physical and mental well-being including better blood pressure and concentration, (2) increased control over patient's own life including time availability, choosing when to dialyze, and dialyzing at home, (3) decreased perception of being sick including returning to regular employment and avoiding sicker patients who must have in-center dialysis, and (4) identification of the competencies and supports required for quotidian dialysis including ability to provide self-care, supportive family, and medical support. Our findings suggest when patients' willingness and physical ability to use quotidian dialysis are coupled with education and support systems to assist patients' and families' self-directed care, patients qualitatively perceive benefits of both increased physical and mental health, both measures of health-related quality of life.