The International Quotidian Dialysis Registry: annual report 2005

The International Quotidian Dialysis Registry was designed to collect data describing treatments, characteristics, and outcomes of patients treated with quotidian hemodialysis (HD) worldwide. In July 2004, North American centers were first invited to enroll patients. By March 1, 2005, a total of 70 nocturnal and 8 short-daily HD patients from three Canadian and two US centers were enrolled. As recruitment continues, projected enrollment for 2005 may exceed 200 patients from North America alone. Preliminary analyses indicate that the current registry cohort is younger (mean age, 49.5 +/- 1.6 years) and carries a lower burden of comorbidity than the overall North American HD population. The low event rate expected in this cohort underlines the need for a large sample size if an appropriately powered survival study is to be undertaken. Increasing recruitment in the United States by including HD centers owned or managed by large dialysis organizations, and beginning overseas collaborations to include Australia, New Zealand, Europe, and South America will be the primary areas of focus for 2005.     

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.     

International quotidian dialysis registry: Annual report 2009

The International Quotidian Dialysis Registry (IQDR) is a global initiative designed to study practices and outcomes associated with the use of hemodialysis regimens of increased frequency and/or duration. Several small studies suggest that compared with conventional hemodialysis (HD), short-daily, nocturnal, and long conventional HD regimens may improve surrogate endpoints and quality of life. However, methodologically robust comparisons on hard outcomes are sorely lacking. The IQDR represents the first-ever attempt to aggregate long-term follow-up data from centers utilizing alternative HD regimens worldwide, and will have adequate statistical power to examine the effects of these regimens on multiple clinical endpoints, including mortality. To date, the IQDR has enrolled patients from Canada, the United States, Australia, and New Zealand, with plans in place to begin linking with additional commercial databases and national registries. This fifth annual report of the IQDR describes (1) a proposed governance structure that will facilitate international collaboration, stakeholder input and funding; (2) data sources and participating registries; (3) recruitment to date and patient baseline characteristics; and (4) an agenda for future research.     

International quotidian dialysis registry: Annual report 2010

The International Quotidian Dialysis Registry (IQDR) is a global initiative designed to study practices and outcomes associated with the use of hemodialysis (HD) regimens of increased frequency and/or duration. The IQDR grew out of the initiative that lead to the randomized prospective studies of nocturnal HD and short hours daily dialysis vs. conventional thrice weekly HD that are conducted by the Frequent Hemodialysis Network sponsored by the National Institutes of Health. These 2 separate studies are drawing to a close and the first results are expected to be reported later this year. These studies use surrogate outcomes for their primary endpoints as they are not powered to look at outcomes of mortality and hospitalization. The IQDR attempts to aggregate long‐term follow‐up data from centers utilizing alternative HD regimens worldwide and will have adequate statistical power to examine those important outcomes. To date, the IQDR has enrolled patients from Canada, the United States, Australia, New Zealand, and France and has linked with commercial databases and national registries. This sixth annual report of the IQDR describes: (1) An update on the governance structure; (2) The recommendations made at the first general meetings of the IQDR Scientific Committee and Advisory Board; (3) The status of those recommendations; (4) A summary of current data sources and participating registries; (5) The status of recruitment to date; (6) The creation of a specific Canadian IQDR data set and; (7) The current research agenda.     

Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials

Hypertension is a common complication of chronic kidney disease and persists among most patients with end‐stage renal disease despite the provision of conventional thrice weekly hemodialysis (HD). We analyzed the effects of frequent HD on blood pressure in the randomized controlled Frequent Hemodialysis Network trials. The daily trial randomized 245 patients to 12 months of 6× (“frequent”) vs. 3× (“conventional”) weekly in‐center hemodialysis; the nocturnal trial randomized 87 patients to 12 months of 6× weekly nocturnal HD vs. 3× weekly predominantly home‐based hemodialysis. In the daily trial, compared with 3× weekly HD, 2 months of frequent HD lowered predialysis systolic blood pressure by ?7.7 mmHg [95% confidence interval (CI): ?11.9 to ?3.5] and diastolic blood pressure by ?3.9 mmHg [95% CI: ?6.5 to ?1.3]. In the nocturnal trial, compared with 3× weekly HD, 2 months of frequent HD lowered systolic blood pressure by ?7.3 mmHg [95% CI: ?14.2 to ?0.3] and diastolic blood pressure by ?4.2 mmHg [95% CI: ?8.3 to ?0.1]. In both trials, blood pressure treatment effects were sustained until month 12. Frequent HD resulted in significantly fewer antihypertensive medications (daily: ?0.36 medications [95% CI: ?0.65 to ?0.08]; nocturnal: ?0.44 mediations [95% CI: ?0.89 to ?0.03]). In the daily trial, the relative risk per dialysis session for intradialytic hypotension was lower with 6×/week HD but given the higher number of sessions per week, there was a higher relative risk for intradialytic hypotensive requiring saline administration. In summary, frequent HD reduces blood pressure and the number of prescribed antihypertensive medications.     

The renaissance of home hemodialysis: where we are, why we got here, what is happening in the United States and elsewhere

Home hemodialysis has been around since 1964, but its use has declined over the years in most countries, this despite its advantages, particularly improved patient survival and quality of life and significant cost savings. Experience has shown that home hemodialysis can be performed successfully by many more patients than at present. Recently, with the demonstration of even better results with more frequent hemodialysis that is obviously best performed at home and with the development of new, more patient-friendly machines, the use of home hemodialysis is beginning to increase again.     

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.     

Home hemodialysis associated infection—The “Achilles' Heel” of intensive hemodialysis

Home hemodialysis (HHD) is emerging as an important alternate renal replacement therapy. Although there are multiple clinical advantages with HHD, concerns surrounding increased risks of infection in this group of patients remain a major barrier to its implementation. In contrast to conventional hemodialysis, infection related complication represents the major morbidity in this mode of renal replacement therapy. Vascular access related infection is an important cause of infection in this population. Use of central vein catheters and buttonhole cannulation in HHD are important modifiable risk factors for HHD associated infection. Several preventive measures are suggested in the literature, which will require further prospective validation.     

The Neglect of Sodium Restriction in Dialysis Patients: A Short Review

In end-stage renal failure, natriuresis decreases, sodium accumulates, and extracellular volume (ECV) excess develops. In 1962, Scribner, reporting about the first maintenance hemodialysis (HD) patient, observed that ECV control using a low-salt diet and ultrafiltration led to blood pressure (BP) normalization. Thus, the concept of dry weight, the ideal postdialysis weight allowing for a stable normal BP, was born. Achieving dry weight requires a combination of negative diffusive sodium balance, adequate ultrafiltration, and a low-salt diet. Unfortunately, the low-salt diet is very often neglected today. In the late 1960s, BP control was achieved in 90% of HD patients using low-sodium dialysis and a low-salt diet. As time passed and HD duration was reduced, there was a worsening BP control and subsequent increasing in morbidity and mortality.
In recent years, interventional studies have examined the effects of reducing sodium in dialysate, in diet, or in both. All of them show that low-salt diet is essential for BP control in HD. While the healthy population is advised to eat a reasonably low-salt diet (5 g of NaCl), the K/DOQI Guidelines and the European Best Practice Guidelines surprisingly do not even mention salt restriction.
To achieve dry weight under the present conditions, with short HD duration and a frail population, it is mandatory to reduce the interdialytic weight gain. A low-salt diet is, more than ever, a necessity.     

The advantages and disadvantages of home hemodialysis

In Australia, 12% of the hemodialysis population dialyze at home. Until recently, the majority of these patients dialyzed for similar hours to those in satellite dialysis. However, in the past 5 years there has been a new departure such that in many centers the concept of home hemodialysis is now synonymous with extended hours dialysis. Registry data supports the concept that increased frequency and duration of dialysis may result in improved patient survival and a reduction in cardiovascular risk profile. It is hoped, therefore, that the long recognized survival benefit observed in home hemodialysis patients may be further augmented by the swing to extended hours dialysis in this patient population. In addition to the physiological benefits of extended hours home dialysis, there are clear quality of life, social, and economic advantages associated with dialyzing at home. There are however a number of perceived disadvantages to home hemodialysis including the application and time commitment required for training, the potential for relationship strain or "burnout," and reluctance to "hospitalize" the home. Overall, however, in this new era of extended hours dialysis, the advantages both physiological and lifestyle of home hemodialysis far outweigh the disadvantages.     

Daily Dialysis: Toward a New Standard in Well‐Being

Daily hemodialysis (DHD) is a promising option; however, logistic obstacles and clinical perplexities limit its dissemination. Understanding the mechanisms of, and the time until, the onset of improved well‐being may help to quantify clinical advantages and to define the minimum length of a “trial” of daily dialysis. By following 30 patients treated in 4 centers, this study aimed to determine how long a period of time is needed until a patient experiences subjective improvement. From November 1998 to November 2000, 30 patients tried at least 2 weeks of short daily dialysis in four Northern Italian centers of Piemonte and Valle d'Aosta. The DHD (2 – 3 hours; blood flow 270 – 350 mL/min; individual HCO₃, Na, K) was performed at home or in a center. Motivations to try DHD, fears and concerns regarding DHD, and changes in perceived well‐being were assessed by semi‐structured interview. The main clinical indications for a trial of DHD were poor tolerance of conventional treatment, cardiovascular disease, and hypertension or hypotension; only 6 patients had no comorbidity at start. The patients' main reasons for choosing DHD were related to job problems and the search for a better treatment. Most of the patients continued DHD because of improved well‐being; logistic reasons accounted for the drop‐outs (5 patients). The main fears were related to logistic aspects, vascular access problems, and excessive involvement of the partner on home dialysis. Improved well‐being was reported by 28 of 30 patients; 2 patients reported no difference. Subjective improvement was perceived within 2 weeks in 22 of 30 patients, and within 1 month in 28 of 30 patients. An offer of a 2 – 4 week trial of DHD may help patients and caregivers to determine whether subjective and objective benefits outweigh logistic problems and whether a permanent transfer to DHD is worthwhile.     

Erythropoietic agents, iron and hemoglobin—What happens beyond the trial setting: Observational data from the ANZDATA Registry

Background: The issues surrounding anemia management in patients receiving dialysis therapy are complex and widely debated. Although numerous trials have been published, clinical practice patterns may differ, particularly in the presence of uncertainty about the optimal management of anemia in this setting. Methods: We examined data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) regarding use of erythropoietic agents (EA), hemoglobin, and ferritin concentrations and transferrin saturation in 8476 prevalent dialysis patients in Australia and New Zealand during the 6 months preceding March 31, 2001. From this cross‐sectional survey, we examined the distribution of reported hemoglobin concentration, transferrin saturation, and ferritin concentration. Among hemodialysis patients, other predictors of hemoglobin examined included urea reduction ratio (URR), age, sex, and the presence of comorbidities. Results: In Australia, 87% of dialysis patients received an EA; in contrast, only 42% of New Zealand patients received an EA. Hemoglobin concentrations were significantly higher in Australia, where 16% of reported values were <100 g/L, compared to New Zealand where 37% reported values were <100 g/L. Transferrin saturation and serum ferritin concentrations were significantly correlated, but less strongly among those receiving EA than those not receiving these agents. Both transferrin saturation and serum ferritin were significantly and independently associated with hemoglobin concentration, as were age and sex. The association with ferritin was inverse: higher serum ferritin concentrations were associated with lower hemoglobin concentrations. There was poor agreement (κ = 0.15) between categories of low transferrin saturation (<20%) and low ferritin concentrations (<200 ng/mL). Among the Australian hemodialysis patients, there was no significant variation in Hb between categories where reported URR was ≥65%, whereas the group with a reported URR <65% had a significantly lower hemoglobin concentration. Conclusions: There was a wide variation in reported hemoglobin concentrations in this population. Potential contributing factors include variable patient responsiveness to EA and iron, differing regulations in Australia and New Zealand regarding government subsidy of EA, and the lack of consensus among physicians regarding hemoglobin target values. Although a cross‐sectional study cannot directly address the predictive value of iron indices for iron deficiency, it appears likely that transferrin and ferritin have different relationships with hemoglobin, and measurement of both may have greater clinical utility than either parameter alone.     

The Practice of Dialysis in the Developing Countries

There are few organized data on the practice of dialysis in developing countries, mostly because of a lack of renal registries. The economic, human, and technical resources required for long-term dialysis make it a major economical and political challenge. Most countries do not have not well-formed policies for treatment of end-stage renal disease. The dialysis facilities are grossly inadequate, and there are no reimbursement schemes to fund long-term dialysis. Hemodialysis units are mostly in the private sector and consist of small numbers of refurbished machines. Water treatment is frequently suboptimal, and this problem has led to a number of complications. Hepatitis B and C infections are widespread in dialysis units. Continuous ambulatory peritoneal dialysis (CAPD) seems to be the ideal dialysis option for patients living in remote areas, but high costs preclude its widespread usage. The Mexican experience suggests that even after it becomes affordable, CAPD needs to be used judiciously. Inadequate dialysis, infections, and malnutrition account for the high mortality among the dialysis population in developing countries. Acute peritoneal dialysis using rigid stylet-based catheters is the main form of dialysis in remote areas. Pediatric dialysis units are almost nonexistent. A significant lack of resources exists in developing countries, making the provision of highly technical and expensive care like dialysis a challenge.