Short Daily Hemodialysis Research Articles

The cardiovascular unphysiology of thrice weekly hemodialysis.

This review examines the unphysiological nature of conventional intermittent hemodialysis (IHD) and explores alternative dialysis modalities that more closely mimic natural kidney function. As cardiovascular complications remain a leading cause of morbidity and mortality in dialysis patients, understanding and addressing the limitations of IHD is crucial for improving outcomes. IHD's intermittent nature leads to significant fluctuations in metabolites, electrolytes, and fluid status, contributing to hemodynamic instability and increased cardiovascular risk. More frequent dialysis modalities, such as short daily hemodialysis and nocturnal hemodialysis have numerous benefits including reduced left ventricular hypertrophy, improved blood pressure control, and potentially decreasing mortality. Peritoneal dialysis offers a more continuous approach to treatment, which may provide cardiovascular benefits through gentler fluid removal and residual kidney function preservation. Conventional thrice weekly intermittent hemodialysis offers a fundamentally unphysiologic equilibrium of uremic solutes. Alternate approaches have demonstrated cardiovascular benefits.

#2567 Protein-bound uremic toxins are better removed with short-daily Home Haemodialysis using low dialysate flow rate: randomized clinical trial results

Abstract Background and Aims Short daily home hemodialysis (HDD) with low dialysate flow rate has been shown in recent years as an attractive alternative for portable dialysis home use. Although the effectiveness of the technique for volume control and elimination of small solutes and middle molecules has been demonstrated, data are scarce for the elimination of protein-bound uremic toxins. The aim of this study was to compare the reduction ratios (RRs) of p-cresol sulfate (pCS) and indoxyl sulfate (IS) in the Physidia HHD system with high-volume online-hemodiafiltration (OL-HDF) treatment. Methods In an open, randomized, cross-over, single-center, controlled study, 40 adult chronic HD patients were treated with a 2.5 h-length HD session with low dialysate flow rate with the Physidia HDD system, and a 4 h-length OL-HDF session in post-dilution mode during two successive weeks. During the sessions, pre-HD and post-HD plasma samples were collected and single and weekly RRs of pC and IS were intraindividually compared for the two dialysis types with linear mixed models. Results Whereas single-session RRs of p-CS and IS were similar in both groups, weekly RRs of both protein-bound uremic toxins were significantly higher with the short-daily HDD Physida system than those obtained with OL-HDF (Table 1). Conclusion The short-daily home hemodialysis using low dialysate flow rate with the Physidia system appears to be a potential technologic step ahead in terms of improved protein-bound uremic toxins removal for dialysis patients, and might contribute to a more adequate dialysis therapy than in-center high-volume online-hemodiafiltration (OL-HDF) treatment.

Exploring the impact of short daily haemodialysis on muscle strength and bone health in end-stage kidney disease patients.

Short-daily haemodialysis (SDH) has been strongly recommended over conventional haemodialysis (CHD) for end-stage kidney disease patients, though few studies have directly compared the effects of these two haemodialysis (HD) modalities on clinical variables related to patient's health. We conducted a cross-sectional study in individuals undergoing HD, comparing epidemiological, clinical, metabolic, inflammatory, anthropometric, bone health/metabolism, and skeletal muscle function according to dialysis modality. One-hundred seventy-eight patients (20.8% females, 62±2.5years old), were analysed in this study, 86 (48%) of whom were undergoing CHD versus 92 (51%) who were undergoing SDH. SDH patients had significantly higher serum albumin levels (3.93 vs. 3.66g/dL, P<0.0001) and higher Kt/v (2.6 vs. 2.38, P<0.0001). SDH group presented a significantly lower number of erythropoietin-stimulating agents compared with CHD group (percentage: 53.3 vs. 83.7%, P<0.0001) and had lower levels of serum phosphate (4.9 vs. 5.3mg/dL, P=0.004) and parathyroid hormone (PTH) (398.4 vs. 480.4pg/mL, P<0.001) compared with CHD patients. In terms of bone health and metabolism, SDH patients had significantly higher total BMD, femur BMD, lumbar BMD, and femoral neck BMD compared with CHD patients (all P<0.05). SDH patients also had lower anti-osteogenic and inflammatory biomarkers, including FGF23, sclerostin, TNF, IL-18, IL-17a, and C-reactive peptide (all P<0.05). CHD modality was demonstrated to be a risk factor for low BMD (odds ratio: 4.02; 95% CI: 1.59-10.2, P=0.003). In terms of skeletal muscle function, SDH patients had significantly higher 6-minute walking test (444.6 vs. 424.9m, P=0.04) and higher fat-free mass (52.3 vs. 51.68kg, P=0.02) compared with CHD patients. Higher fat-free mass and handgrip strength were associated with a 34% and 23% lower risk of low BMD, respectively. SDH patients had lower levels of the uremic toxin asymmetric dimethyl-l-arginine (ADMA) (1.8 vs. 2.07μM, P=0.002) and fasting blood glucose (132.6 vs. 141.7mg/dL, P<0.02) than CHD group. SDH patients also displayed higher levels of haemoglobin when compared with CHD group (11.9 vs. 10.2g/dL, P<0.0001). The present study improves our understanding of the relationship between dialysis modality and clinical variables that may influence HD patient's health. Grip strength and lean mass were positively correlated with bone mineral density in HD patients regardless of dialysis modality. SDH was associated with better bone mineral density, inflammatory profile, and skeletal muscle function when compared with CHD patients. These findings provide more evidence of the clinical benefits of SDH that should be explored in greater detail.

Intradialytic resistance training for short daily hemodialysis patients as part of the clinical routine: a quasi-experimental study.

Background and purpose: Hemodialysis patients have chronic systemic inflammation, musculoskeletal impairments, and body composition changes from several factors and exercise may attenuate. We evaluated the effects of an intradialytic resistance training program on body composition, physical function, and inflammatory markers in patients under short daily hemodialysis treatment. Materials and methods: A quasi-experimental study in clinical routine was conducted over eight months. Measures of physical function (handgrip strength, five-time sit-to-stand, timed-up and go, and gait speed), body composition (by bioelectrical impedance), and inflammatory markers (interleukin [IL]-1 beta, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-α) were assessed at baseline as well as at four and eight months past continued intervention. Patients underwent two intradialytic resistance training sessions per week supervised by exercise professionals. Results: A total of 18 patients (62 ± 14years; 55.6% ≥ 60years; 44% female) were included. Significant increases in body mass index and basal metabolic rate were found at four and eight months compared to baseline. For physical function, timed-up and go performance improved at four and eight months compared to baseline. The other body composition and physical function measures, as well as all inflammatory markers, did not significantly change over time. Conclusion: A supervised intradialytic resistance training program for patients on short daily hemodialysis treatment, as part of the clinical routine, may induce modest changes in body mass index, basal metabolic rate, and timed-up and go performance.

Paradoxical Protection of Keeping an In-Center Short Daily Hemodialysis Schedule During the First 2 Years of COVID-19 Pandemic

Paradoxical Protection of Keeping an In-Center Short Daily Hemodialysis Schedule During the First 2 Years of COVID-19 Pandemic

Implementing a resistance training programme for patients on short daily haemodialysis: A feasibility study.

Kidney failure patients receiving haemodialysis experience protein-energy wasting, muscle mass lossand physical function impairment. Intradialytic exercise interventions seem to modify these features, but they are often not implemented as a clinical routine. To investigate the feasibility of implementing a supervised intradialytic resistance training programme as a clinical routine for patients receiving short daily haemodialysis. A prospective longitudinal study. Eighteen patients in a supervised intradialytic resistance training programme for 8 months. It consisted of a warm-up, lower- and upper-limb resistance exercisesand a cool-down. Patients performed the resistance training during the first half of haemodialysis, twice a week, supervised by exercise physiologists and physiotherapists. The feasibility was assessed by the total and partial adherences, the reasons for refusing or for not exercisingand the intradialytic complications. From a total of 953 potential exercise sessions, 759 were performed, with a 79.6% adherence rate. In the first 9 weeks, the adherence rate was 86.6% and the lowest rate was in the 19-27 weeks (73.5%). The main intradialytic complication during exercise sessions was hypotension (n = 31; 4.1%). The highest number of complications was reported during the first 9 weeks (n = 27; 9.1%). The main reasons for refusing or for not performing the intradialytic exercise sessions were clinical complications previous to exercise time (n = 63; 32.5%) and self-reported indisposition (n = 62; 32.0%). The intradialytic resistance training programme, supervised by exercise physiologists and physiotherapists, had very low complications, achieved a high long-term adherence rate and showed to be feasible as a clinical routine for patients receiving short daily haemodialysis.

MO661: Elimination of Middle and Large Uraemic Toxins in Short Daily Home Haemodialysis with Low Dialysate Volume: A Randomized Crossover Clinical Trial

Abstract BACKGROUND AND AIMS Portable haemodialysis (HD) systems with a low dialysate flow rate in a short frequent schedule have become an attractive option for patients on home HD (HHD). Although these systems have been demonstrated to be effective for removing low weight molecular uraemic toxins, there are few data on their removal ability of higher molecular weight toxins. This study assessed the uraemic toxin removal ability of the portable Physidia S3 Monitor in a short, frequent, 5 days/week, low-dialysate flux HHD versus 3 days/week, in centre online haemodiafiltration (OL-HDF). METHOD In an open, randomized, cross-over, single-centre, controlled, prospective study, 40 adult chronic HD patients were treated by a 2.5-h low flux dialysate HD session or a 4-h post-dilution OL-HDF. All other dialysis parameters including dialyzer (polysulfone high-flux dialyzer NS 1.8, Toray®) were kept constant in both the study arms. The weekly reduction rate (RR) and the weekly eliminated mass into dialysate (EM) of urea, creatinine, phosphate, β2-microglobulin, kappa (κFLC) and lambda (λFLC) free light chains and albumin, were intra-individually compared for the two dialysis types with linear mixed models. RESULTS There were no significant differences in the RR for urea, phosphate, κFLC and albumin, whereas the weekly RRs for creatinine and β2-microglobulin were significantly higher with the Physidia S3 system than those obtained with OL-HDF (Table). Only the λFLC RR was significantly higher with OL-HDF. Similar results were observed when weekly EMs were compared (data not shown). CONCLUSION This study demonstrates that treating patients with low flow dialysate HHD in a short frequent schedule with Physidia S3 system, instead of 3 days/week, in-centre OL-HDF, significantly increases the weekly elimination of β2-microglobulin, enabling an adequate clearance of small and large uraemic toxins.

MO935: A Propensity-Matched Study of The Effect of Short Daily Home Haemodialysis With Low Flow Dialysate on Nutritional Status and Body Composition

Abstract BACKGROUND AND AIMS The present study tested the hypothesis that short daily home haemodilaysis (HDD) with low flow dialysate using the NxStage monitor (Fresenius Medical Care) could preserve muscle mass and prevent protein-energy wasting in HD patients, despite using low-flux, lactate-buffered dialysate. METHOD This 12-month, prospective, controlled study examined 25 consecutive, non-selected CKD stage 5 patients who initiated short daily HHD with low-flow dialysate (HHD group) in our centre, and were compared with data from 50 patients on high-flux HD (HF-HD group) and 50 patients on on-line haemodiafiltration (OL-HDF group) obtained from the Fresenius Medical Care clinical database EuCliD after matching for clinical characteristics and propensity scores. Changes in body composition were assessed by whole-body bioimpedance spectroscopy (BIS; Fresenius Medical Care) at baseline, months 3, 6 and 12, by experienced research staff blinded to all clinical and biochemical data of the patients. In order to control for potential variability and the effect of overhydration, all BIS analyses were performed before a mid-week dialysis session. Linear mixed-effects models were used for the analysis of the repeated measures data. RESULTS Compared with in centre HF-HD, patients assigned to HHD experienced a gradual improvement in LTM. These differences reached statistical significance at Month 6 and Month 12, with a relative difference of 2.76 kg [95% confidence interval (95% CI): 0.53–4.99; P = 0.01] and 3.08 kg (95% CI: 0.68–5.45; P = 0.01), respectively. Changes in fat inversely mirrored those of LTM, with a relative difference between groups of –3.29 kg (95% CI: –6.66–0.07; P = 0.05) at Month 12. No differences in hydration status or dry weight were noted between groups (Table 1). No significant changes in body composition were observed between the HDD and the OL-HDF groups (data not shown). CONCLUSION Short daily HHD with the NxStage system for 1 year compared with HF-HD increased muscle mass, supporting the hypothesis that short daily HHD with low-flow dialysate could benefit nutritional status and prevent protein-energy wasting in HD patients.

Safety and Efficacy of Short Daily Hemodialysis with Physidia S3 System: Clinical Performance Assessment during the Training Period.

Background: A growing body of scientific evidence indicates that clinical outcomes of hemodialysis patients can be improved with short daily dialysis treatment. Current in-center hemodialysis machines do not fulfill the requirements needed for self-care home hemodialysis (HHD) treatment. In line with the reviviscence of home therapy, several hemodialysis devices have been developed and deployed for treatment. Physidia S3 is one of these new dialysis delivery systems featuring an appealing design and functionalities intended for daily HHD treatment. Methods: In this French multicenter proof-of-concept study enrolling 13 training centers, we report our preliminary experience with a special focus on quantifying clinical performances in short daily HHD treatment performed during the training period of the patients. Results: Among the 80 patients included in this study, a total of 249 sessions could be analyzed. Dialysis dose, estimated from weekly standardized Kt/V, was maintained at 2.22 [1.95–2.61] with a normalized protein catabolic rate of 0.93 [0.73–1.18] g/kg/24 h. Furthermore, anemia and nutritional status were adequately controlled as indicated by 11.6 ± 1.4 g/dL of hemoglobin level and 39.4 ± 5.7 g/L of serum albumin as well as electrolyte disorders. Conclusions: The safety and efficacy of the S3 therapy concept relying on a short daily hemodialysis treatment using a bagged delivery system are in total agreement with daily HHD recommendations. Clinical performances are aligned to the metabolic needs of the vast majority of HHD patients. Currently ongoing studies at home will provide further evidence and value of this therapeutic approach.

Early results and medico-economic evaluation of a short daily home hemodialysis program in a Private hemodialysis center

Abstract: Between 2015 and 2017 there was a 40% increase in daily hemodialysis, according to the REIN database. This increase concerns 1% of patients and the private sector remains under-represented. Our retrospective study aims to describe the clinical features, the organizational and medico-economic specificities of this technique in a private hemodialysis center.&#x0D; Methods: We included 12 dialyzed patients trained on Nx Stage® machine from February 2020 to April 2021. Data were retrospectively obtained through review of our electronic medical records (EUCLID®).&#x0D; Results: Of the 12 patients trained, 11 dialyzed from home, with an average follow-up of 9 months (1-14). The average age was 45 with a sex ratio of 4/8 (M/W), and a median Charlson score of 3 (2-4). The average residual urinary output was 700 mL/24h, and 50% of patients were anuric. 100% of patients had an arteriovenous fistula and were cannulated using the buttonhole technique. 9 patients are on a transplant list. One patient needed anticoagulants. The mean training time was 35 days (28-35). 83% of patients were dialyzed 6 days a week with an average duration of 210 minutes (130-150) per session. The average volume of dialysate was 24.85 liters. One patient developed an allergy to the PUREMA® membrane. Pre-dialytic hemoglobin, serum creatinine, urea, phosphoremia and B2-microglobuline are stable at 9 months with improvement in metabolic acidosis.&#x0D; Conclusion: DHHD allowed a better socio-professional integration. One patient received a transplant and 3 patients resumed professional activity.

Novel Use of Premixed Dialysate Bags during Water Supply Interruption in Acute Hospital Setting.

Patients on dialysis are exposed to large amounts of water during conventional intermittent hemodialysis; hence, there are strict regulations regarding the quality of water used to prepare dialysate. Occasionally, water systems fail due to natural disasters or structural supply issues, such as water-main breaks or unplanned changes in municipal or facility water quality. It is critical to regularly monitor and immediately recognize such a failure and take steps to avoid exposing the patients to contaminants. In addition to the recognition of the problem, the ability to pivot and continue to provide safe treatment to inpatients who are dependent on dialysis is essential, both from an ultrafiltration and a clearance standpoint. At our hospital, an unforeseen water disruption occurred and we were able to continue to provide KRT with premade, bagged dialysate to mitigate the effect on our patients on dialysis. This is a novel method using available machines and dialysate, which we normally stock for continuous KRT, for short dialysis sessions. The methodology is similar to that which has been widely used for short daily home hemodialysis with low dialysate flow rate. Because this situation occurred in the midst of the SARS-CoV-2 pandemic, we had to be mindful of dialysate volumes and staffing time. Here, we present our investigation into the cause of the water-system failure and how we quickly implemented the alternative dialysis method. Short dialysis with low-flow dialysate will not deliver the same Kt/V per session as standard dialysis; however, this method was successfully implemented and tailored with adjustments for patients requiring higher clearance for specific indications, such as severe hyperkalemia.

P1055REMARKABLE REMOVALS OF BETA-2-MICROGLOBULIN AND PHOSPHATE WITH SHORT-DAILY HOME HEMODIALYSIS USING LOW DIALYSATE FLOW RATE

Abstract Background and Aims Short-daily hemodialysis (HD) with low-dialysate volume is an appealing portable dialysis approach for home use. Although this type of HD has proved being effective for the volume control and the clearance of low molecular-weight uremic toxins, limited data are available on the impact on the removal rates of other uremic toxins like β2-microglobulin (β2M) or phosphate (P), whose clearance is limited by sequestration into compartments, poor diffusion, high time-dependency, or protein binding. We evaluated the impact of short-daily HD with slow dialysate flow rate on the removal of solutes of different molecular weights and distribution volumes. Method Single-session and weekly balances of β2M, P, urea, and creatinine were prospectively assessed with total dialysate collection and serum measurements before and after 341 dialysis sessions (mean dialysate volume: 30963 ± 862 mL; mean length of dialysis session: 153 ± 8 min) in 31 stable patients (female; 9, 29 %; mean age: 55.6 ± 13.6 y; dry weight: 74.9 ± 13.3 kg) undergoing short-daily home HD with NxStage cycler, between July 2014 and October 2019. The mean blood flow rate was 365 ± 17 mL/min, whereas the mean dialysate flow rate was 194 ± 12 mL/min. Results Single-session β2M, P, urea, and creatinine removals were 0.138 ± 0.050 g, 0.610 ± 0.161 g, 18.89 ± 6.07 g and 1.07 ± 0.31 g, respectively, whereas the reduction rates (%) were 38.0 ± 13.0, 46.8 ± 8.6, 48.2 ± 7.0 and 46.6 ± 6.6, for β2M, P, urea and creatinine, respectively. The estimated weekly β2M, P, urea and creatinine removals in HDD patients dialyzing 5-6 days per week were comparable with 4-h in-center thrice-weekly on-line hemodiafiltration according to previous studies (Table 1). Conclusion Treating patients with short-daily HD with low-dialysate volume at a 5-6 days per week prescription may achieve an efficient weekly β2M and P removal.

Association between extracellular volume control and survival in patients on short daily haemodialysis

BackgroundFluid overload (FO) assessed by bioimpedance spectroscopy (BIS) is associated with higher mortality risk in maintenance haemodialysis (HD). The aim was to assess if a better management of FO through short daily haemodialysis (SDHD) could improve survival.MethodsRetrospective analysis of patients who were on HD 3 sessions/week for at least 3 months and shifted to in-centre SDHD (5 or 6 sessions/week, 2 to 3 h/session) between July 2012 and June 2016 at 23 dialysis units in Brazil. The 12-month risk of death was analysed according to the predialysis hydration status measured before and 6 months after initiation of SDHD. Predialysis hydration status was considered adequate when FO ≤15% of extracellular volume.ResultsA total of 297 patients on SDHD were included in the analysis. Their median age was 57 (IQR 45–67) years, 62% were males, 44% diabetics, 57% on 6 dialysis sessions/week, with a median session duration of 130 (IQR 120–150) minutes. BIS assessment at initiation of the SDHD regimen was performed in 220 patients and FO > 15% was found in 46.4%. Twelve-month survival rates for those with FO ≤15 and > 15% before initiating SDHD were 87.4 and 88.0%, respectively (P = 0.92). BIS analysis when completing 6 months on SDHD were available for 229 patients, 26.6% with FO > 15%. The survival rates for the next 12 months (from the 6th to the 18th month of follow-up) for those with FO ≤15 and > 15% were 91.0 and 72.0%, respectively (P = 0.0006). In a Cox regression model, after adjustment for demographic, clinical and laboratory variables, FO ≤ 15% persisted associated with a lower mortality risk (hazard ratio 0.34, 95%CI 0.13–0.87).ConclusionsMoving from conventional HD to SDHD was associated with better control of excessive extracellular volume. Patients who reached or maintained predialysis fluid overload ≤15% after initiating SDHD presented a lower risk of death.

Expanded home hemodialysis: case reports.

Among the different hemodialysis (HD) strategies, the short daily hemodialysis performed at home (SDHHD) provides clinical benefits to the patient. Expanded hemodialysis (HDx) employs cutoff medium membranes that exhibit greater clearance capacity of uremic toxins of medium-high molecular weight. This case series study reported the results of seven patients who were transferred to expanded hemodialysis at home (HHDx), from December 2017 to March 2019, over a 12-month follow-up period. The AK-98 monitor and Theranova 400 membrane (Baxter International Inc., Deerfield, IL, USA) were used. The main outcome measures were blood analytical values and drug consumption. The blood levels of β2-microglobulin were significantly reduced (p = 0.0082), while maintaining albumin levels with less use of phosphorus binders. Regarding the safety profile, technique-related adverse events were not reported. According to the results of the current study, HHDx was a safe technique, which additionally had the ability to provide benefits to patients due to its greater purification capacity. Further studies, especially multicenter ones, with a greater number of patients are needed to confirm these results.

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers.

Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.

FP749The effect of short daily home hemodialysis with low-flow, lactate-buffered dialysate on nutritional status and body composition

FP749The effect of short daily home hemodialysis with low-flow, lactate-buffered dialysate on nutritional status and body composition

Daily hemodialysis practices in Australia/New Zealand and in France: a comparative cohort study

BackgroundAs patients on daily hemodialysis (DHD) have heterogeneous profiles, DHD benefit in terms of survival is still debated. The aim of this study was to compare DHD practices in France and in Australia and New Zealand.MethodsThis study was based on data from the French Renal Epidemiology and Information Network (REIN) and the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). All incident patients from both registries who underwent DHD (i.e., 5–6 sessions/week, including short daily hemodialysis and long nocturnal hemodialysis) at least once during their trajectories were included, and their characteristics and care trajectories were compared. For survival analyses, one French patient was matched to one Australian or New Zealand patient, based on age, sex and year of dialysis start. Survival was assessed using the Cox proportional hazards model, and access to renal transplantation was evaluated using the Fine & Gray model to take into account death as competing risk.ResultsBetween 2003 and 2012, 523 patients from the AZNDATA and 753 from the REIN registry started DHD. ANZDATA patients were younger (54.8 vs 64.0 years, p < 0.001) and had comorbidities more frequently than French patients. In both registries, one third of patients were on early DHD (i.e., DHD started less than one year after dialysis initiation). Long nocturnal hemodialysis was more frequent in the ANZDATA than in the REIN cohort (20.8 and 3%, respectively). Comparison of the matched subgroups showed comparable survival rates between French and Australian/New Zealand patients (HRadjusted = 1.08; 95%CI: 0.78–1.50). Access to renal transplantation also was similar between matched groups (SHRadjusted = 1.30, 95%CI: 0.86–1.97).ConclusionsOur study shows that, despite differences in terms of patients’ characteristics and DHD regimens, the mortality risk and access to renal transplantation are similar in France and Australia and New Zealand.

Antibiotic Dosing in Chronic Kidney Disease and End-Stage Renal Disease: A Focus on Contemporary Challenges.

Infections are an important cause of morbidity and mortality among patients with chronic kidney disease. Therefore, appropriate antibiotic dosing is imperative to achieve positive patient outcomes while minimizing antibiotic dose-related toxicity. Accurately assessing renal function and determining the influence of renal replacement therapy on antibiotic clearance makes drug dosing in this patient population challenging. Furthermore, as technological advances in hemodialysis and peritoneal dialysis occur, research incorporating newer dialysis parameters to guide drug dosing may not be readily available. Currently, there are limited data to guide drug dosing in the setting of automated peritoneal dialysis, short daily hemodialysis, and nocturnal hemodialysis. Antibiotic-dosing recommendations should be carefully evaluated considering the accuracy of the renal function assessment, the similarity of the operating characteristics of the renal replacement therapy studied compared with those being used, and whether the dosing strategy takes advantage of the pharmacodynamic profile of the antibiotic under consideration. After implementing the antibiotic-dosing regimen, therapeutic drug monitoring should occur when possible along with careful monitoring for antibiotic efficacy and safety.

Survival Comparisons of Home Dialysis Versus In-Center Hemodialysis: A Narrative Review.

Purpose of review:Many observational studies have demonstrated a survival benefit with home dialysis compared with in-center dialysis; however, results have been conflicting. The purpose of this review was to identify pitfalls and limitations in existing literature and examine the challenges of studying home and in-center dialysis populations.Sources of information:Original research articles were identified from MEDLINE using search terms “in-center hemodialysis,” “home hemodialysis,” “conventional hemodialysis,” “nocturnal hemodialysis,” and “short daily hemodialysis.”Methods:A focused review and critical appraisal of existing home versus in-center hemodialysis survival literature was conducted to identify potential causes for variability in the observed survival outcomes.Key findings:The controversy in existing literature stems from the challenges of randomizing patients to home versus in-center hemodialysis modalities, and therefore a reliance on observational comparisons for study. In many cases, these observational analyses have been limited by selection bias (variabilities in populations included, inclusion of both incident and prevalent cohorts, and variabilities in dialysis intensity), as well as residual confounding. Furthermore, the studies that do exist lack generalizability in many cases.Limitations:There are few randomized controlled trials examining the survival benefit of home versus in-center hemodialysis and existing observational studies are often limited by bias and reduced generalizability. These limitations comprise the body of this review.Implications:This review examines challenges surrounding survival comparisons with home versus in-center hemodialysis and identify important directions for future study.

Pharmacokinetic Study of Cefazolin in Short Daily Hemodialysis.

A number of centers across the world offer short daily hemodialysis (SDHD) treatments. To date, cefazolin pharmacokinetics have not been described in patients undergoing SDHD. The purpose of this study was to investigate the effect of SDHD on the pharmacokinetics of cefazolin. This was a prospective, open-label, pharmacokinetic study of cefazolin during SDHD in 10 noninfected patients. Participants received a 1-g intravenous (IV) infusion of cefazolin after SDHD on study day 1 and a second dose after SDHD on study day 2. To determine the concentration of cefazolin, 6 blood samples were drawn at 0, 1, 2, 2.3, 4, and 24 hours after initiation of dialysis on day 2, and 2 dialysate samples were drawn at 1 and 2 hours after initiation of dialysis on day 2. Samples were analyzed using high-performance liquid chromatography, and pharmacokinetic parameters were determined. Median interdialysis clearance was 0.16 L/h (interquartile range [IQR]: 0.11-0.21 L/h), and median intradialysis clearance was 1.95 L/h (IQR: 1.66-2.45 L/h). Median interdialysis half-life was 28.2 hours (IQR: 23.5-59.3 hours) as compared with a median intradialysis half-life of 2.3 hours (IQR: 1.7-2.7 hours). The median percentage removal of cefazolin during dialysis was 41% (IQR: 35%-53%). Conclusion and Relevance: Estimated cefazolin dialysis clearance is similar to previous estimates with conventional thrice-weekly regimens. Current dosing recommendations of 1 g IV post-SDHD achieve total serum drug concentrations greater than 40 mg/L in all patients, which is the total drug concentration required for bactericidal activity against Staphylococcus species.