Why Our Patients Like Daily Hemodialysis

The option of daily hemodialysis (HD) was discussed in November 1998 with a group of 35 HD patients on home or self‐care/limited‐care HD in a single, freestanding unit. After the meeting, 3 patients on home HD chose to switch to daily HD. The clinical success of the first patient and the immediate followers was one of the main reasons for further extension of this experience. At the time of this writing (February 2000), 10 patients were on a daily HD program (8 at home and 2 in a self‐care/limited‐care center) and one was in training for home daily HD. One further patient who tried 1 month of daily HD dropped out for logistic reasons. On daily HD, patients are dialyzed 2 – 3 hours/day, 6 days/ week, with blood flow of 270 – 300 mL/min, on bicarbonate dialysate with individually determined levels of Na and K. The schedule is flexible and a switch to 3 – 4 dialyses/week is occasionally allowed for working needs or for vacation. In addition to the well‐known clinical advantages (better well‐being, blood pressure control, nutrition, etc.), some patients preferred daily HD because of easier organization of daily activities, including work schedule. Patients initially feared frequent needle punctures and excessive burden on partners, but those concerns proved to be less a problem than anticipated. All current patients are willing to continue daily HD; only a nursing shortage limits further extension of the program in the self‐care/limited‐care center.     

Home hemodialysis in Australia: current perspective

Home hemodialysis (HD) in Australia represents 11% of the dialysis population. This percentage has declined over the last 20 years but the absolute number of home HD patients has increased since 2001. The major reason for this resurgence has been the institution of nocturnal HD at home. Predominantly, this has been as a strictly alternate day exercise, although 5-6 times per week dialysis is also practised. Short-daily HD is uncommon in Australia. Nocturnal HD now comprises 30% or more of all home HD. Most home HD in Australia is practiced without remote monitoring, using simple machines with separate reverse osmosis units. Patients tend to self-needle and not all have a "partner." The enthusiasm for nocturnal HD in particular has been fuelled by ANZDATA Registry data demonstrating a survival advantage for patients dialyzing alternate days compared with 3 times per week; and for patients dialyzing for >18 hours per week compared with 12 or 15 hours per week.     

Personal Support Worker (PSW)‐supported home hemodialysis: A paradigm shift

Introduction: Despite improving clinical outcomes associated with the use of home hemodialysis (HD), its utilization is low in most countries. The inability or unwillingness of patients and their families to participate in their own treatment is one of the most important barriers to the adoption of home HD. Methods: We hypothesized that paid helper‐delivered home HD supported by public funds would be successful and welcomed by patients and be delivered at an affordable cost. We conducted a pilot project to dialyze six patients at home using Personal Support Workers (PSW) and resolve regulatory, organizational and financial constraints. Findings: cWe provided publically‐funded PSW‐supported home HD to six patients. We describe the administrative structure of the pilot project allowing scalability and turnkey operation in the province of Ontario. Regulatory and insurance concerns were resolved and patients and staff were enthusiastic. The projected total dialysis cost, when economies of scale are met, are expected to be lower than the cost of in‐center HD. Discussion: A second phase of the project is currently under way including 8 hospitals and 67 patients. If equally successful, it may have significant implications for the delivery of care for End Stage Renal Disease in Ontario and similar jurisdictions. It promises to increase the utilization of home dialysis possibly at a lower cost than in‐center HD. This would be particularly important in providing dialysis in underserviced and geographically hard to access areas.     

Doppler echocardiograph evaluation of pulmonary hypertension in patients undergoing hemodialysis

Pulmonary hypertension (PH) has been reported in hemodialysis (HD) patients, but data regarding its incidence and mechanisms are scarce. The aims of this study was to evaluate the prevalence of unexplained PH in long-term HD patients, and to examine some possible etiologic factors for its occurrence. The prevalence of PH was estimated by Doppler echocardiography in a cohort of 86 stable patients on HD via arteriovenous access for more than 12 months. All the patients underwent full clinical evaluation, chest radiography, and a standard 12-lead echocardiograph. Laboratory investigation included a mean of 12 months (serum calcium, phosphorus, parathormone (PTH), alkaline phosphatase, lipids, and hemoglobin). Pulmonary hypertension was defined as pulmonary artery systolic pressure >35 mmHg as determined by Doppler echocardiography using the modified Bernoulli equation. Pulmonary hypertension was detected in 23 patients (26.74%). Of those with PH, left ventricular hypertrophy was seen in 13 patients (56.52%), and valvular calcifications in 6 patients (26.08%). There were no significant differences between both groups with regard to age, sex, duration of dialysis, shunt location, and all the biological parameters of the study. The presence of PH was not related to the level of PTH, or the severity of other metabolic abnormalities. This study demonstrates a high prevalence of PH among patients with ESRD receiving long-term HD via surgical arteriovenous access. The role of the vascular access, anemia, or secondary hyperparathyroidism as the etiology of PH in HD patients did not hold in this study.     

The ideal home hemodialysis machine

Daily home hemodialysis (HD) patients have a much superior survival rate than patients on regular, 3 times a week in-center HD or on peritoneal dialysis. Present-day HD machines are unsuitable for use at home by patients. We present our concept of the ideal home HD machine that allows daily short and long HD, does all the work preparing for and cleaning up after dialysis, has an intravenous infusion system controlled by the patient, needs no systemic anticoagulation, and teaches and interacts with the patient during dialysis. To fulfill these functionalities, the dialyzer and blood tubing must be integrated with the machine and replaced less often than monthly, the machine must be capable of at least 200 L/week of hemodiafiltration, prepare all fluids necessary between and during dialyses, and all the components and fluids must be much beyond ultrapure.     

Plasma vitamin C levels in ESRD patients and occurrence of hypochromic erythrocytes

Introduction: The achievement of erythropoiesis in hemodialysis (HD) patients is typically managed with erythropoiesis‐stimulating‐agents (ESA's) and intravenous iron (IV‐iron). Using this treatment strategy, HD patients frequently show an elevated fraction of red blood cells (RBC) with hemoglobin (Hb) content per cell that is below the normal range, called hypochromic RBC. The low Hb content per RBC is the result of the clinical challenge of providing sufficient iron content to the bone marrow during erythropoiesis. Vitamin C supplements have been used to increase Hb levels in HD patients with refractory anemia, which supports the hypothesis that vitamin C mobilizes iron needed for Hb synthesis. Methods: We conducted a cross‐sectional survey in 149 prevalent HD patients of the percent hypochromic RBC, defined as RBC with Hb < 300 ng/uL of packed RBC, in relation to plasma vitamin C levels. We also measured high‐sensitivity CRP, (hs‐CRP), iron, and ferritin levels. and calculated ESA dose. Findings: High plasma levels of vitamin C were negatively associated with hypochromic RBC (P < 0.003), and high ESA doses were positively associated (P < 0.001). There was no significant association of hs‐CRP with percent hypochromic RBC. Discussion: This finding supports the hypothesis that vitamin C mobilizes iron stores, improves iron delivery to the bone marrow, and increase the fraction of RBC with normal Hb content. Further research is warranted on development of protocols for safe and effective use of supplemental vitamin C for management of renal anemia.     

Home hemodialysis: Beliefs,attitudes, and practice patterns

There is increasing interest of the worldwide kidney community in home hemodialysis (HHD). This is due to emerging evidence of its superiority over conventional hemodialysis (HD), largely attributed to improved outcomes on intensive schedule HD, best deployed in patient's own homes. Despite published work in this area, universal uptake remains limited and reasons are poorly understood. All those who provide HD care were invited to participate in a survey on HHD, initiated to understand the beliefs, attitudes, and practice patterns of providers offering this therapy. The survey was developed and posted on the Nephrology Dialysis Transplantation‐Educational (NDT‐E) website. Two hundred and seventy‐two responses were deemed suitable for complete analysis. It is apparent from the survey that there is great variability in the prevalence of HHD. Physicians have a great deal of interest in this modality, with majority viewing home as being the ideal location for the offer of intensive HD schedules (55%). A significant number (21%) feel intensive HD may be offered even outside the home setting. Those who offer this therapy do not see a financial disadvantage in it. Many units identify lack of appropriately trained personnel (35%) and funding for home adaptation (50.4%) as key barriers to widespread adoption of this therapy. Despite the interest and belief in this therapy among practitioners, HHD therapy is still not within reach of a majority of patients. Modifiable organizational, physician, and patient factors exist, which could potentially redefine the landscape of HHD provision. Well‐designed systematic research of national and local barriers is needed to design interventions to help centers facilitate change.     

Quality of life, self-care ability, and sense of coherence in hemodialysis patients: a comparative study

The number of patients treated for end-stage renal disease has increased in Sweden as in the rest of the world. During the last 6 years, more than 1000 people per year started renal replacement therapy in Sweden. Today hemodialysis (HD) patients have the opportunity to choose from different treatment modalities, home HD, self-care dialysis or conventional dialysis. The aim of the study was to investigate whether there are differences in the way HD patients view their quality of life, self-care ability and sense of coherence if they dialyze themselves at home, dialyze themselves in center (self-care), or if they are dialyzed by nurses in an outpatient dialysis unit. The instruments consisted of the Short Form 36 (SF-36) health survey, the Appraisal of Self-Care Agency questionnaire and the Sense of Coherence questionnaire. Nineteen patients participated in the study (5 patients on home HD, 6 self-care patients and 8 patients on conventional in center dialysis). There was a tendency for those who dialyzed at home to score higher on quality of life, self-care ability and sense of coherence than those who dialyzed themselves in center. Since the number of participants in this study was low, it is necessary for future studies to include more patients to verify the results.     

The source of net ultrafiltration during hemodialysis is mostly the extracellular space regardless of hydration status

Fluid shifts are common in patients undergoing chronic hemodialysis (HD) during the intradialytic periods, as several liters of fluid are removed during ultrafiltration (UF). Some patients have experienced frequent intradialytic hypotension (IDH). However, the characteristics of fluid shifts and which fluid space is affected remain controversial. Therefore, we designed this study to evaluate the fluid spaces most affected by UF and to determine whether hydration status influences the fluid shifts during HD. This was a prospective cohort study of 40 patients undergoing HD. We measured the patient's fluid spaces using a whole‐body bioimpedance apparatus to evaluate the changes in the fluid spaces before HD and 1–4 hours of HD and 30 minutes after HD. UF achieved during HD by the 40 patients (age, 60.0 ± 5.2 years; 50% men; 50% of patients with diabetes; body weight, 61.3 ± 10.5 kg) was 2.18 ± 0.78 L (measured fluid overload, 2.15 ± 1.24 L). 1) Mean relative reduction of total body water and extracellular water was reduced from the start to the end of HD. 2) However, mean relative reduction of intracellular water was not reduced from the start to the end of HD. 3) No significant differences in fluid shifts were observed according to hydration status. The source of net UF during HD is mostly the extracellular space regardless of hydration status. Thus, IDH may be related to differences in the interstitial fluid shift to the vascular space.     

The International Quotidian Hemodialysis Registry: rationale and challenges

Outcomes from conventional thrice-weekly hemodialysis (CHD) are disappointing for a life-saving therapy. The results of the HEMO Study show that the recommended minimum dose (Kt/V) for adequacy is also the optimum attainable with CHD. Interest is therefore turning to alternative therapies exploring the effects of increased frequency and time of hemodialysis (HD) treatment. The National Institutes of Health have sponsored 2 randomized prospective trials comparing short hours daily in-center HD and long hours slow nightly home HD with CHD. An International Registry has also been created to capture observational data on patients receiving short hours daily in-center HD, long hours slow nightly home HD, and other alternative therapies. Participation by individual centers, other registries and the major dialysis chains is growing and currently data from nearly 3000 patients have been collected. Pitfalls in data collection have been identified and are being corrected. A matched cohort (patients in other registries) study is planned to obtain information regarding hard outcomes expected from these therapies. The Registry may become the most important source of information required by governments, providers, and the nephrological community in assessing the utility of such therapies.     

Using water wisely: New, affordable, and essential water conservation practices for facility and home hemodialysis

Despite a global focus on resource conservation, most hemodialysis (HD) services still wastefully or ignorantly discard reverse osmosis (R/O) "reject water" (RW) to the sewer. However, an R/O system is producing the highly purified water necessary for dialysis, it rejects any remaining dissolved salts from water already prefiltered through charcoal and sand filters in a high-volume effluent known as RW. Although the RW generated by most R/O systems lies well within globally accepted potable water criteria, it is legally "unacceptable" for drinking. Consequently, despite being extremely high-grade gray water, under current dialysis practices, it is thoughtlessly "lost-to-drain." Most current HD service designs neither specify nor routinely include RW-saving methodology, despite its simplicity and affordability. Since 2006, we have operated several locally designed, simple, cheap, and effective RW collection and distribution systems in our in-center, satellite, and home HD services. All our RW water is now recycled for gray-water use in our hospital, in the community, and at home, a practice that is widely appreciated by our local health service and our community and is an acknowledged lead example of scarce resource conservation. Reject water has sustained local sporting facilities and gardens previously threatened by indefinite closure under our regional endemic local drought conditions. As global water resources come under increasing pressure, we believe that a far more responsible attitude to RW recycling and conservation should be mandated for all new and existing HD services, regardless of country or region.     

Hemodialysis does not impair ventricular functions over 2 years

We aimed to evaluate the long-term effect of hemodialysis (HD) treatment on left and right ventricular (LV and RV) functions in patients with end-stage renal disease. The study population consisted of 22 patients with newly diagnosed end-stage renal disease. Before an arteriovenous fistula was surgically created for HD, the patients were evaluated by echocardiography for systolic and diastolic functions. After the first HD session (mean 24.22 ± 2.14 months), the second echocardiographic evaluations were performed. Left ventricular and RV functions before and after long-term HD treatment were compared. The mean age was 55 ± 13 years and 10 (45%) of the patients were female. After long-term HD treatment, the isovolumic relaxation time was significantly decreased; however, the peak early (E) and late (A) diastolic mitral inflow velocities, E/A ratio, and deceleration time of E wave were not significantly different from the baseline measurements. Also, there was no significantly change in the early diastolic velocity (Ea) of the lateral mitral anulus and the E/Ea ratio. Pulmonary vein peak diastolic velocity, peak atrial reversal velocity, and peak atrial reversal velocity duration remained almost unchanged even though the pulmonary vein peak systolic velocity and the pulmonary vein peak systolic velocity/pulmonary vein peak diastolic velocity ratio were significantly lower after long-term HD treatment. In addition, LV systolic functions, LV diameters, LV mass index, left atrium size, and RV diastolic functions were not statistically different after long-term HD treatment. The myocardium is exposed to hemodynamic, metabolic, and neuro-humoral abnormalities during HD treatment; however, the long-term effects of HD on ventricular functions are not clearly known. The present study showed that the long-term effects of HD on LV and RV functions were insignificant in patients with end-stage renal disease. We have demonstrated that the LV and RV functions did not change significantly after long-term HD treatment. We suggest that this result may be due to regulated blood pressure levels of the patients, treatment of anemia and other metabolic disorders during the HD period and the prevention of weight gain and hypervolemia.     

What happened in Finland to increase home hemodialysis?

Finland is geographically a rather large country with a relatively sparse population (5.3 million). Home hemodialysis (HHD) was started in Helsinki 40 years ago and in the early years it was only used in selected patients. However, by the late 1980s HHD almost disappeared owing to the advent of CAPD and new HD centers. Towards the end of the 1990s, it became evident that PD had limitations and new ways had to be found to individualize HD, improve the outcome, increase capacity, and limit the growth of costs of HD. After careful planning, HHD was reinstituted at the Helsinki University Hospital in 1998 and since then the program has grown steadily. By December 31, 2007, altogether 163 patients had started at home. This has required changes in the predialysis program where the "home first" policy was adopted. Other important features include close cooperation with other nephrological centers as well as centralized HHD training that also supports more remote hospitals. Since then this therapy has been started in several other academic and in some smaller hospitals, and at the end of last year about 4% of all Finnish dialysis patients (n=1.600) were on HHD (prevalence 11.8/million). In the Helsinki metropolitan area this treatment is the most economical modality (estimated annual global costs euro37.000), comparable to self-care satellite HD and CAPD. A successful HHD program requires a well-organized predialysis program, a highly motivated multidisciplinary team, and well-developed training networks.     

The effect of hemodialysis duration on 703 hemodialysis patients in our center

There are limited data on demographics, long‐term follow‐up, and iron/rHuEPO requirements of hemodialysis (HD) patients in Turkey. The aim of the study was to analyze the effects of the HD duration, primary illness, blood pressure, and age on serum albumin, CRP, blood pressure, iron/rHuEPO requirements, PTH, and HCV positivity of HD patients. 703 patients (280 women, 423 men, aged 47.8 ± 15.5 years) from 4 HD units were included and grouped according to the duration on HD. The demographic, clinical, and biochemical data of the last 3 months for each patient were recorded retrospectively. When the groups were compared, patients with a longer HD duration were younger and percentage of diabetic patients decreased as the duration increased. Serum albumin and CRP levels were similar between the groups. When the groups were compared according to the blood pressure profiles, after the 5^th year, a decline in the systolic blood pressures was observed. Diastolic blood pressures were similar across the years. There was no significant difference in need of antihypertensive medicines. Iron requirements showed a fall after the 5^th year, and an increase in after the 10^th year. There was a decline in the hematocrit levels by the duration on HD but there was no change in rHuEPO requirements over the years. Parathyroid hormone levels and HCV positivity tended to increase across the years. Our results revealed that during the first 10 years, age, etiology (diabetes, hypertension), and blood pressure control seemed to be important factors affecting survival. Whereas, after the 10^th year, patients seemed to be more prone to the long‐term complications of HD, such as HCV infection, anemia, secondary hyperparathyroidism.     

Telematics Service for Home and Satellite Hemodialysis

Home hemodialysis (HD) for the treatment of end-stage renal disease was first implemented about 30 years ago. In this paper the application of telematics monitoring services for supporting patients who need home HD or satellite HD is described. Two modified HD machines were located in two renal units, and a central control station (CCS, UNIX workstation with multimedia PC terminal) was located in another room of the hospital. Bidirectional communication between the modified HD machines and the CCS was managed using ISDN (Integrated Services Digital Network) links. Nine patients had 150 HD sessions performed using these HD machines over a period of 5 months. This system, called the HOMER-D system, provided on-line, remote supervision of the HD machine-related functions and the clinical condition of the patients through measurement of blood pressure, pulse rate, PO₂ (pulse oxymetry), and ECG from the CCS. Any disturbances in the functioning of the HD machines were both visible and audible in the CCS, and the observer could give teleconsultation to the renal unit staff. No major dialysis-associated complications were observed; all data and alarms were transmitted correctly; and patients received adequate HD treatment.     

Overproduction of reactive oxygen species in end-stage renal disease patients: a potential component of hemodialysis-associated inflammation

During the past decade, hemodialysis (HD)-induced inflammation has been linked to the development of long-term morbidity in end-stage renal disease (ESRD) patients on regular renal replacement therapy. Because interleukins and anaphylatoxins produced during HD sessions are potent activators for nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, an example of an enzyme that is responsible for overproduction of reactive oxygen species (ROS), this may constitute a link between leukocyte activation and cell or organ toxicity. Oxidative stress, which results from an imbalance between oxidant production and antioxidant defense mechanisms, has been documented in ESRD patients using lipid and/or protein oxidative markers. Characterization of HD-induced oxidative stress has included identification of potential activators for NADPH oxidase. Uremia per se could prime phagocyte oxidative burst. HD, far from improving the oxidative status, results in an enhancement of ROS owing to hemoincompatibility of the dialysis system, hemoreactivity of the membrane, and trace amounts of endotoxins in the dialysate. In addition, the HD process is associated with an impairment in antioxidant mechanisms. The resulting oxidative stress has been implicated in long-term complications including anemia, amyloidosis, accelerated atherosclerosis, and malnutrition. Prevention of oxidative stress in HD might focus on improving the hemocompatibility of the dialysis system, supplementation of deficient patients with antioxidants, and modulation of NADPH oxidase by pharmacologic approaches.     

Hemodialysis‐induced regional left ventricular systolic dysfunction

Introduction Hemodialysis (HD) patients are under observably elevated cardiovascular mortality. Cardiac dysfunction is closely related to death caused by cardiovascular diseases (CVD). In the general population, repetitive myocardial ischemia induced left ventricular (LV) dysfunction may progress to irreversible loss of contraction step by step, and finally lead to cardiac death. In HD patients, to remove water and solute accumulated from 48 or 72 hours of interdialysis period in a 4‐hour HD session will induce myocardial ischemia. In this study, we evaluated the prevalence and potential risk factors associated with HD‐induced LV systolic dysfunction and provide some evidences for clinical strategies. Methods We recruited 31 standard HD patients for this study from Fudan University Zhongshan hospital. Echocardiography was performed predialysis, at peak stress during HD (15 minutes prior to the end of dialysis), and 30 minutes after HD. Auto functional imaging (AFI) was used to assess the incidence and persistence of HD‐induced regional wall motion abnormalities (RWMAs). Blood samples were drawn to measure biochemical variables. Findings Among totally 527 segments of 31 patients, 93.54% (29/31) patients and 51.40% (276/527) segments were diagnosed as RWMAs. Higher cTnT (0.060 ± 0.030 vs. 0.048 ± 0.015 ng/mL, P = 0.023), phosphate (2.07 ± 0.50 vs. 1.49 ± 0.96 mmol/L, P = 0.001), UFR (11.00 ± 3.89 vs. 8.30 ± 2.66 mL/Kg/h, P = 0.039) and lower albumin (37.83 ± 4.48 vs. 38.38 ± 2.53 g/L, P = 0.050) were found in patients with severe RWMAs (RWMAs in more than 50% segments). After univariate and multivariate analysis, interdialytic weight gain (IDWG) was found as independent risk factor of severe RWMAs (OR = 1.047, 95%CI 1.155–4.732, P = 0.038). Discussion LV systolic dysfunction induced by HD is prevalent in conventional HD patients and should be paid attention to. Patients would benefit from better weight control during interdialytic period to reduce ultrafiltration rate.