Science & medical journals: hemodialysis
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Prevent buttonhole infections with Mupirocin
The Buttonhole technique for fistulas lessens needle pain, missed cannulations, and bumpy aneurysms. The only downside? A higher risk of staph infection. A new study finds that prescription mupirocin (Bactroban®) ointment, an antibiotic, reduced that risk by 35 times! Read the abstract.
Patients: Buttonholes feel AND look better
Among 53 people doing HD, 93% had shorter bleeding times with the Buttonhole technique, 81% had less needle pain, and 80% felt that their fistulas looked better. Fewer people needed surgery to fix their fistulas, too. Read the abstract.
PD and home HD don't compete with each other
A new study finds that different people are attracted to PD vs. home HD. Those who chose PD tended to be older, female, and have diabetes and/or high blood pressure. Those who chose home HD were younger, more likely to be male, and had heart or blood vessel disease. Both treatment options are growing worldwide (perhaps because they're better?!). Read the abstract.
Antibiotic ointment aids Buttonhole safety
The only downside of the Buttonhole technique for dialysis needles has been a higher risk of infection. That risk can be reduced, finds a new study. No patient who put mupirocin (Bactroban®) ointment on Buttonholes after treatment got an infection. Read the abstract.
Better blood pressure control with short daily HD
In a new study of 12 patients switched from standard to daily HD, blood pressure was less variable on daily treatments—and drops during treatment were significantly reduced. (These changes may help explain the better survival on this treatment.) Read the abstract.
Better sleep rhythms with nocturnal HD
Who sleeps best on dialysis? A new study found the most normal levels of melatonin (a hormone that helps control sleep patterns) in people who did nocturnal HD. Those on PD also had better sleep than people who did standard in-center HD. Read the abstract.
Give me a D!
No, it's not your grade in math. A new study has found that deficiency of vitamin D (the sunshine vitamin) is present in 79% of people on dialysis—especially if they start treatment in the winter. Too-low levels have been linked to bone and heart disease. Ask your doctor if your levels are where they should be. Read the abstract.
42% higher risk of death found with less-than-4-hour HD
Short standard in-center HD treatments done 3 times a week were linked with a much higher risk of death in a new study of 8,552 people. Of course, "further studies are needed...." Read the abstract.
A Brazil nut a day keeps the doctor away
Heart disease risk is higher among people on HD, due to oxidative stress (basically rust). Selenium reduces this stress—and Brazil nuts are the best known source. In a new study, 81 people on HD ate one Brazil nut each day. At the end of 3 months, their levels of the protective enzyme GSH-Px were normal. Read the abstract.
Nocturnal HD improves bone mineral levels
Yes, we knew this—but this time, it's a randomized controlled trial of nocturnal (6 nights/week) vs. standard in-center HD (3 times/week). Compared to standard HD, those doing nocturnal had lower phosphorus—even without binders—lower PTH levels, and lower calcium-times-phosphorus products. Read the abstract.
For lupus, HD may be a better option
A small study of 36 women with lupus in Taiwan has found much better survival and less inflammation in those who did HD. Protein levels were higher on HD, too. Read the abstract.
Better nutrition with nocturnal HD
A new study found better appetites, more energy, and higher protein intake in people doing 6 nights/week nocturnal HD. Even though they ate more foods high in phosphorus, their blood levels stayed good without binders. They were able to drink more fluids, too. Read the abstract.
To reduce inflammation: Get rid of your HD catheter
Even with no infection, an HD catheter can still trigger inflammation. In a new study, people who got a fistula and had a catheter removed had an 82% lower c-reactive protein (CRP) level 6 months later. Those who kept the catheter had a 16% higher CRP. Read the abstract.
Nocturnal HD normalizes smooth muscle cells
Blood vessel calcification is an all-too-common problem among people on dialysis. On standard HD, fewer smooth muscle cells grow inside the blood vessels, and more of them die. Switching from standard to nocturnal restored normal cell growth—and also lowered blood pressure, and PTH and phosphate levels. Read the abstract.
The WAK is back...
The wearable artificial kidney (WAK) is still in development. In this most recent article, the developers have learned that a pulsing, rather than steady, flow of dialysate improves clearance of wastes. Activated charcoal is used to absorb Beta-2 microglobulin (which can cause dialysis-related amyloidosis). A dialyzer with a larger surface area and higher dialysate pH are also being tested. Read the abstract.
Nocturnal HD protects blood vessels
Damage to smooth muscle cells may be one reason why people on standard in-center HD tend to have more clogged and calcified arteries. In 15 patients studied before and after switching from standard HD to nocturnal HD, there was better smooth muscle growth and less cell death on nocturnal. (Blood pressure, PTH levels, and phosphorus levels improved, too.) Read the abstract.
Finally, data! Buttonhole Technique causes fewer fistula problems than site rotation
A new study compares 75 HD patients using the Buttonhole technique for fistula needles with 70 patients using the "standard" technique of "rope ladder" needle site rotation. Buttonhole users had fewer missed cannulations, bruises, and aneurysms, and needed less angioplasty. Infection precautions are vital: there was a higher infection rate. Read the abstract.
Access-challenged people on HD have a new HeRO
Running out of vascular access sites is no laughing matter. A new fully implantable dialysis catheter helps solve the infection risk that occurs when a catheter goes through the skin and into a central vein. In a new study of 36 people, the Hemodialysis Reliable Outflow (HeRO) had infection rates similar to grafts. Read the abstract.
Better stats help prove the value of more dialysis
It's clear to us that more dialysis is more like having healthy kidneys. But the statistic used to measure the risk of death ("proportional hazards model")...didn't quite succeed. A new statistical model based on when the kidneys fail and toxins start to build up DOES find a strong relationship. In fact, each 0.1 unit increase in Kt/V improved survival by 3.5%! Read the abstract.
New study: Survival benefit for nocturnal HD
Researchers from the U.S. and Canada matched each of 94 people on nocturnal HD and 43 on short daily HD to 10 controls on standard HD. Even using the "proportional hazards model" (see next item, below), they found a significantly lower risk of hospitalization and death on nocturnal, and a lower (but not significant) risk for daily, too. Read the abstract.
Nocturnal HD survival matches that of deceased donor transplant
A new study used data from two Canadian programs and the USRDS (1994 to 2006) and randomly matched each of 177 people doing nocturnal HD to three people who'd had transplants. During up to 12 years of follow-up, 14.7% of the nocturnal dialyzors died, vs. 14.3% of those who'd had deceased donor transplants, and 8.5% of those who'd had living donor transplants. Read the abstract.
Fresenius publishes home study of 2008K machine
A newly-released study follows 29 stable HD patients in-center for 6 months and then at home for 6 months on 2008H or K machines. While in-center, patients had 5.84 adverse events per 100 treatments—which dropped to just 3.34 events per 100 treatments at home. Read the abstract.
Dialysate regeneration for home HD
Dr. Ronco's been busy: he is also a co-author on an article this month about a system to use two activated carbon columns to regenerate dialysate. Read the abstract.
Home FIRST—a new paradigm
Why is the least effective—and most costly—form of treatment the default choice in the U.S.? A new article asks this question, and suggests that we present treatment options in terms of home vs. in-center, rather than HD vs. PD. Read the abstract.
In-center HD pill burden lowers quality of life
Taking (and paying for) an average of 19 pills each day (with a strict fluid limit!) reduces health-related quality of life in people using standard in-center HD, a new study finds. Of course, every form of home treatment requires fewer pills! Read the abstract.
First report from the Frequent Hemodialysis Network (NIH) studies!
There are two FHN studies. One compares 6-days-a-week in-center HD to 3-days-a-week. The other looks at 6-nights-a-week home nocturnal vs. 3 standard home HD treatments. So far, the study shows that more-frequent HD really is a LOT more dialysis—enough that the results should be able to prove whether more is truly better. Read the abstract.
In-center nocturnal—another good option
Canada found that folks switched from standard in-center HD to nocturnal in-center HD (3 nights/week) used less EPO and had better sleep, quality of life, appetite, and energy. They also had fewer cramps. Read the abstract.
Switching from standard to nocturnal HD has many benefits
We bet you won't be surprised to learn that the 13 patients studied had much lower BP (with fewer drugs), higher hemoglobins (with fewer ESAs), better nutritional status, and lower calcium-phosphorus product. (PTH rose in some, though.) Read the abstract.
Hope predicts a better adjustment to dialysis
How important is hope? A new study finds that hopeful people on dialysis were less anxious and depressed and had fewer symptoms. (We'd bet that home dialyzors are more hopeful.) Read the abstract.
HD frequency vs. length: Which matters most?
For toxin removal, are you better off with more frequent HD, or longer treatments? Turns out that longer HD removes significantly more creatinine & methylguanidine than standard or more frequent treatments—but the combination of BOTH was best (you knew we'd say that!) Read the abstract.
Get drier: Live longer
A 3.5 year long study of 269 people on HD has found that folks who had more water removed from the blood (tested with a body composition monitor) lived significantly longer than those who stayed water-logged. (Drier is better, and doing longer and/or more frequent HD makes that possible.) Read the abstract.
Mind the gap
In the UK, "mind the gap" means watch your step as you get off the train. For in-center HD, the gap is the 2-day dialysis weekend. It turns out that switching randomly chosen patients from 3x/week to every other day HD for 12 months reduced blood pressure, left ventricular mass, EPO dose, urea rebound, and symptoms. Of course; it's more physiological! Read the abstract.
Nocturnal HD improves melatonin rhythm for better sleep
Is sleep better or worse on nocturnal HD, since it is done at night? A new study of 13 people who switched from standard HD to nocturnal found that standard HD disrupts the normal rhythm of melatonin (the hormone that helps you sort out day from night). After 6 months of night-time treatments, this rhythm was partly restored—and sleep was much better. Read the abstract.
If you can't beat 'em, zap 'em!
Fibrils of amyloid can build up in the joints and soft tissues when too-little beta-2 microglobulin (B2M) is removed from the blood during dialysis. Longer and more frequent treatments remove more B2M. But what if we could remove fibrils that have already occurred? A new study suggests that laser treatments can destroy existing fibrils and slow the rate of new ones. Read the abstract.
Children on dialysis have good survival prospects
Some of the longest survivors of ESRD were children or teens when their kidneys failed. A new study finds that 5-year survival of this group after they reach age 18 was 95.1%, with an average life expectancy of age 63 with a transplant—or age 38 with standard dialysis. Of course, two recent studies have found that survival with longer and/or more frequent HD rivals that of transplant. Read the abstract.
Lower b2m levels predict better survival
More frequent—and especially longer—HD remove much more beta-2 microglobulin, a toxin that causes dialysis-related amyloidosis (DRA), with waxy protein deposits in bones, joints, and sometimes soft tissues. Since a new study has found that lower levels of B2m on dialysis predict survival, getting more dialysis is a plus! Read the abstract.
Treatment length matters (we knew that!)
Even when the same number of blood liters are processed, long, slow dialysis does a better job of removing toxins. In a study where patients on HD were dialyzed for 4, 6, or 8 hours, the longer treatments removed significantly more urea, creatinine, phosphorus, and beta-2 microglobulin. The authors conclude that Kt/V should not be the only measure of dialysis adequacy. Read the abstract.
Why Canadians choose self-care dialysis
A new study randomized 70 new ESRD patients into standard options classes or to have the benefits of self-care taught with a booklet, video, and small group brainstorms. Compared to the group getting standard education, benefits group patients who valued lifestyle were 7 times more likely to choose self-care; those who valued freedom were 9.1 times more likely. Read the abstract.
Poor sleep on standard in-center HD
Good sleep on dialysis improves survival. A new study compared sleep quality on standard in-center HD and a control group matched for age, sex, body mass index, and race. The in-center HD patients had significantly worse sleep. Read the abstract.
Consistent Aspirin use associated with improved AVF survival among incident HD patients in the DOPPS
A new paper from the Dialysis Outcomes & Practice Patterns Study (DOPPS) reports that people who took aspirin had significantly less fistula failure than those who didn't. (Talk to your doctor about whether a baby aspirin or an adult aspirin might benefit you). Read the abstract.
Secondary arteriovenous fistulas: Converting prosthetic AV grafts to autogenous dialysis access
Dialysis fistulas tend to have fewer clots, infections, and hospital stays than grafts. Switching from a graft to a fistula was highly (90%+) successful after 2 years in a new study. Read the abstract.
Matching home dialysis to lifestyle
A "continuum home program concept" described in a new article would help people with kidney failure continue their lifestyles with dialysis—rather than disrupt them with treatment. The aim is for a continuous flow of services from education to treatment choice, dialysis access, and option changes when needed. Read the abstract.
Take your vitamins
A new study finds that HD—with regular or high flux membranes—removes large amounts of water soluble vitamins. Read the abstract.
Daily HD survival compares to transplant
A study by Kjellstrand et. al. pooling data from 1006 short daily HD patient years (415 patients, both at home and in-center) found 2-3 times better survival than on standard in-center HD. In fact, survival with daily HD was similar to that of deceased donor transplant. (Interesting that no-one disputes that survival is better with transplant than standard HD—though patients are selected for it (just as for home HD) and no randomized controlled trial has been done.) Read the abstract.
Travel time to HD predicts HRQOL, adherence, & death
A new paper from the Dialysis Outcomes and Practice Patterns (DOPPS) study of 20,994 patients reports that patents whose one-way travel to HD was longer than 60 minutes had significantly higher mortality and lower quality of life. Patients noted, "I feel as if it rules all my time." The authors suggest home dialysis as an option for those who live far from the nearest center. Read the abstract.
No kidding: daily HD has better quality of life than standard in-center HD
Okay, we're not surprised to find that a metaanalysis of 17 papers comparing daily HD to standard HD found that folks using daily treatment had fewer access problems, better blood pressure control, less LVH, better anemia control, needed fewer phosphate binders—and had better quality of life. Read the abstract.
On dialysis and want a baby? Think about nocturnal HD
The numbers are very small—but in a new study, 5 women ages 31-37 had 7 pregnancies between them and 6 live infants while receiving 43-53 hours of nocturnal HD per week. Two of the infants were small for gestational age, and one was premature. None of the women (from Toronto) had conceived while doing standard HD. Read the abstract.
More blood pressure meds + standard HD doesn't = better BP
Both daily and nocturnal HD can aid blood pressure control and reduce the need for BP meds. But do more BP meds on their own help blood pressure in patients on standard therapy? A new study says NO. Among 106 ESRD patients, those who took 4+ BP pills had no better blood pressure than those who took 2-3 or 0-1. Read the abstract.
High ultrafiltration (UF) rates stress the heart
Standard in-center HD requires high UF rates to remove fluid. A 5-year prospective study of 287 dialyzors from 2007 found this is a BAD idea. During the study, 149 patients died—69% due to heart problems. Survival was better with UF less than 12.37 ml/h/kg—which is much more doable at home. Read the abstract.
Fewer heart problems with nocturnal HD
A new 2-year study from Canada looked at 42 folks on standard HD and 32 on nocturnal HD. Hospital stays for heart problems dropped in those using nocturnal, but stayed the same for the standard dialyzors. Lower phosphorus and better anemia control were also found in those using nocturnal. Read the abstract.
Stable hemoglobin levels predict survival in HD
An analysis of 34,963 dialyzors found that variations in hemoglobin were harmful. In fact each 1 g/dL increase in hemoglobin variability raised the risk of death by 33%—even after adjusting for many other factors. Good anemia management can help you live longer. Read the abstract.
Human trial reports on wearable artificial kidney (WAK) in UK
The competition for better home HD gets even hotter! This month's Lancet includes an article about use of the WAK in 5 men and 3 women, who tried the device for 4-8 hours. There were no adverse heart, electrolyte, or acid-base events—though some access problems did occur, and dialysis itself is not yet optimal. It's still cool, though. Read the abstract.
Study finds survival advantage for home hemo over in-center
A new retrospective Swiss study (Nephrology Dialysis Transplantation Jan 2005, 20:604-610) matched 58 home hemo (HHD) patients with 58 in-center patients on sex, age, length of time on dialysis, and cause of kidney failure. The researchers found better survival among the HHD patients at 5 (93% vs. 64%), 10 (72% vs. 48%), and 20 years (34% vs. 23%). Read the abstract.
Effects of short daily versus conventional hemodialysis on left ventricular hypertrophy and inflammatory markers: a prospective, controlled study
Inflammation and a condition called left ventricular hypertrophy (LVH) are key risk factors for heart damage in people on dialysis. Drs. Ayus and Achinger have summarized their study which compared the heart effects of conventional vs. short daily hemo. They found that short daily treatments reduced phosphorus levels and LVH by more than 30%—and also reduced inflammation. Read all about it.
Wearable artificial kidney a step closer?
A company called National Quality Care presented its newly patented wearable artificial kidney (WAK) at the recent American Society of Nephrology meeting in Philadelphia. Invented by Dr. Victor Gura, the WAK is vastly smaller than current machines, and will permit 24/7 dialysis. Read the patent application to learn how it will work.
Home hemo rates vary more than other modalities
A paper published in this month's Nephrology Dialysis Transplantation by Drs. Macgregor, Agar, and Blagg found more variation in the rates of home hemo between countries than any other type of dialysis. The authors concluded that "significant expansion of home HD is likely to be possible in most countries, and will be increasingly important as the impressive results of more frequent HD gain credence." Read more.
Kids & dialysis: daily and nocturnal hd have benefits
Imagine being a child and having to limit sodium, phosphorus, and fluids. A new article about pediatric HD reports outcomes from a program in France. Children using daily HD needed no fluid or diet limits except potassium, while those on nocturnal HD had no limits at all. Read the abstract.
Predialysis education increases use of home therapies
In a randomized, controlled study done in Canada, of the patients who were assigned to see a 15-minute video on self-care dialysis, read booklets, and attend a 90-minute small group session, 82.1% chose a home dialysis option. Among the "usual care" group, only 50% did. (So, even usual care in Canada far surpasses what we do in the US!) Read the abstract.
Intensive hemo helps heart health
After a year of short daily home HD 6 days/week or nocturnal home HD 3.5 nights/week, patients had no change in 24 hour blood pressure vs. controls on standard in-center HD. But those getting "intensive" (longer or more frequent) HD needed fewer blood pressure pills, their left ventricular mass decreased, and they had better phosphate control with fewer binders. Those who stayed on standard HD did worse in each area. Read the abstract.
Nocturnal HD improves cognitive function
Fuzzy thinking on in-center HD? A new study suggests that nocturnal HD can help. Patients who switched to nocturnal HD had a 22% fewer cognitive symptoms and 32% better attention and working memory after 6 months. Read the abstract.
Switching from standard to nocturnal HD improves vitamin D levels
In 35 patients who did nocturnal HD for 6 months or more, levels of active vitamin D rose significantly. The study patients had no diet limits, and their serum phosphorus levels fell after the switch from in-center HD. Normalizing phosphorus levels may help the body to produce more active vitamin D. Read the abstract.
Nocturnal HD helps bone mineral status
Doing nocturnal home HD every other night helps bone minerals stay at more normal levels than standard treatments, say researchers from Australia in a new study. After 26 patients switched from standard (home) to nocturnal HD, their serum phosphorus and calcium-phosphorus products fell, most needed no binders, and bone mineral density was stable. Plus, blood vessel calcification improved or at least was stable in 87.5%. Read the abstract.
New study finds better survival with short daily home hemo
Compared to USRDS survival figures for conventional (3 times a week) in-center hemo, 117 people using short daily home hemo had a significantly lower standardized mortality rate, found a study by Drs. Blagg, Kjellstrand, Ting, and Young. Read the abstract.
Redefining HD adequacy based on phosphorus
High phosphorus levels in dialyzors cause a host of life-threatening problems—but a higher HD dose based on urea clearance doesn't save lives. In this month's Seminars in Dialysis, a new article suggests that we use phosphorus removal as a marker instead. Daily and nocturnal HD both remove more phosphorus than standard HD. It's time to give another marker a try. Read the abstract.
Lying down during dialysis beats sitting up, new study suggests
When we lie down, our blood plasma volume expands, and when we sit up, it contracts. A new study concludes that nocturnal dialysis causes smaller day-to-day shifts in hemoglobin and serum albumin (protein) than standard, seated treatments. Read the abstract.
More dialysis, longer life
In 2003, researchers from the 12-nation Dialysis Outcomes and Practice Patterns (DOPPS) study found that HD treatments shorter than 3.5 hours had a 33% higher risk of death. A new DOPPS paper reports that each extra 30 minutes of HD reduces the relative risk of death by 7%. Unfortunately, this study also documented mean US in-center treatment times of...3.5 hours. Read the abstract.