Blood Access Outcomes Associated with Short Daily Hemodialysis

With the growing number of reports that daily hemodialysis (DHD) improves clinical outcomes and quality of life, there has been increased interest in the effects of more frequent venipunctures on blood accesses. Since 1996, we have converted 30 patients (27 in‐center, 3 home) from conventional 3/week dialysis to short, daily, 6/week dialysis (sDHD). Twenty‐five patients started for medical indications. End‐stage renal disease (ESRD) causes were diabetes mellitus (in 7), hypertension (6), glomerulonephritis (8), hereditary nephritis (2), and other (7). Mean (±SD) age was 57 ± 16 years. Patients had an average of 3.8 major comorbidities in addition to ESRD. Thirty patients were followed on sDHD for 388 patient‐months: 9 patients died after 4.2 ± 6.7 months, 3 were transplanted at 5.4 ± 2.2 months, and 3 were disenrolled at 9.3 ± 10.5 months. Fifteen patients remain on sDHD at 20.4 ± 14.1 months. Access problems for the 12 months prior to sDHD were compared to those that occurred while the patient was on sDHD. Problems were tracked by access type. There were 40 different accesses in 30 patients with a cumulative 28.07 access‐years pre‐DHD; 24 of these accesses were artificial bridge grafts (ABG) of either polytetrafluoroethylene or bovine material. There were 27 access problems pre‐DHD, or 0.962 problems per access‐year. On sDHD these same 30 patients had 41 accesses for 34.44 access‐years; 23 of these were ABGs. There were 31 access problems or 0.900 problems per access‐year. There were no significant differences in access problems comparing pre‐DHD with on‐sDHD, either in aggregate or when analyzed by access type. After 39 months of observation, there does not appear to be an increase in blood access problems when patients are converted from conventional dialysis to sDHD.     

Short and long nightly hemodialysis in the United States

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.     

Hemodialysis access at initiation in the United States, 2005 to 2007: Still "Catheter First"

Despite the broad consensus that native arteriovenous fistula is the access of choice for hemodialysis, national-level information about vascular access at dialysis initiation has been unavailable in the United States. For incident hemodialysis patients, June 2005 to October 2007 (n=220,157), vascular access type was determined from the new Centers for Medicare & Medicaid Services Medical Evidence Report (form CMS-2728). Proportions with each type at first dialysis, demographic and clinical associations of each type, and associations between initial access type and survival were assessed. The mean patient age was 63.6 years; 29.4% of patients were African American, and for 44.5%, end-stage renal disease was due to diabetes. Vascular access proportions were: fistula, 13.2% of patients; graft, 4.3%; catheter/maturing fistula, 16.0%; catheter/maturing graft, 3.3%; and catheter alone, 63.2%. Adjusted odds ratios (vs. fistula) of catheter use alone were ≥1.50 for lack of insurance (1.62 [95% confidence interval 1.62–1.68]), nephrologist care for 0 to 12 months (2.75 [2.69–2.81]), other (2.19 [2.09–2.29]), or unknown (1.53 [1.44–1.63]) cause of renal disease, institutional residence (1.51 [1.45–1.57]), and 7 of 18 end-stage renal disease networks. Over a mean follow-up of 1 year, 26.0% of the study population died. Compared with fistula, adjusted mortality hazards ratios were 1.39 (1.32–1.47) for grafts, 1.49 (1.44–1.55) for catheters/maturing fistulas, 1.74 (1.65–1.84) for catheters/maturing grafts, and 2.18 (2.11–2.26) for catheters alone. While geographic variability is pronounced, vascular access at dialysis inception is typically suboptimal; suboptimal access exhibits a graded association with mortality. Lack of timely access to specialty care appears to limit optimal access.