Science & medical journals: hemodialysis
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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.