What Went Wrong with Home Hemodialysis in the United States and What Can Be Done Now?

In 1973, almost 40% of the more than 10 000 dialysis patients were treated by home hemodialysis. Today, with more than a quarter of a million dialysis patients in the United States, fewer than 2000 are on home hemodialysis. A number of factors have contributed to this change. First, many nephrologists and administrators who were developing new dialysis units had little or no practical experience with dialysis for chronic renal failure. Second, more elderly and diabetic patients were admitted to treatment. Home hemodialysis was more difficult for such patients, and often their helpers were themselves were elderly. Third, hemodialysis machines were difficult to learn and operate. Fourth, following publication of the results of the National Cooperative Dialysis Study, there developed the erroneous concept that a Kt/V equal to 1.0 was “adequate dialysis.” As bigger dialyzers became available, there was a widespread shortening of dialysis time. This decrease in time was embraced by for‐profit dialysis facilities and inadequately educated patients, and assembly‐line dialysis became generally accepted. Finally, continuous ambulatory peritoneal dialysis, with its simplicity and short training time, began to fill the need of many patients for home dialysis and independence, at least temporarily. Fortunately, the trend is now reversing. Two developments clearly have benefits for home hemodialysis. The first is an increasing interest in the use of more frequent dialysis. The second is the development of new equipment designed specifically for use by the patient, and requiring a minimum of effort on the patient's part.     

Dialysis adequacy and nutritional status of hemodialysis patients

To characterize the nutritional status of renal failure patients and its relationship with hemodialysis adequacy measured by Kt/V, a study was carried out with a population of 44 adult patients with renal failure and mean age 51+/-15 years. Anthropometric data, such as dry weight, height, arm circumference, triceps skinfold thickness, mid-arm muscle circumference, and body mass index were assessed, and biochemical tests were conducted for urea, potassium, creatinine, serum albumin, and phosphorus levels, in addition to hemogram and quarterly urea reduction rate average (Kt/V). In order to evaluate calorie intake, a dietary questionnaire on habitual daily food ingestion was administered, taking into consideration the hemodialysis date. The patients were divided into 2 separate groups for the statistical analysis, with 50% of the patients in each group: A (Kt/V<1.2) and B (Kt/V>1.2). The data were tabulated as mean and standard deviation, with differences tested by Student's t test. The correlations between variables were established by the coefficient p of Pearson. Most of the patients (43%) were considered eutrophic, based on the BMI, and presented inadequate calorie intake, corresponding to 88.5+/-24% (30.8 kcal/kg actual weight) of the total energy required and adequate protein intake, reaching 109.9+/-40% of the recommended daily allowance (1.24 g/kg of actual weight). There was a correlation of Kt/V with anthropometric parameters such as body mass index, arm circumference, and mid-arm muscle circumference. The biochemical parameters related to dialysis adequacy were albumin, ferritin, and urea (predialysis). Well-dialyzed patients presented better levels of serum albumin. There was an influence of gender and age on correlations of the analyzed variables. Female and younger patients presented better dialysis adequacy. The dialysis adequacy was related to the nutritional status and influenced by the protein intake and body composition. Gender and age had an important influence in the dialysis adequacy, as men presented lower dialysis adequacy and younger adults presented better dialysis adequacy. Further research is necessary to understand better how to facilitate effective and efficient techniques for the nutritional status assessment of hemodialysis patients.     

Clinical consequences of heparin-free hemodialysis

Heparin-free hemodialysis (HF-HD) has been increasingly used in patients at risk for bleeding, especially in the intensive care unit (ICU). Lack of heparin can reduce solute clearances in continuous hemofiltration; the effect on HD is undefined. Failure to recognize an effect of the anticoagulation strategy upon delivered clearance could contribute to the known problem of underdialysis in the ICU. In addition, the consequences of "locking" dialysis catheters with concentrated heparin solutions are also unclear. This study was designed to define the clinically relevant consequences of HF-HD and catheter locking. In part I, we performed 200 HD treatments on inpatients, of which 100 were performed with heparin, and 100 were performed as HF-HD. We calculated prescribed and delivered Kt/V and dialysis efficiency. In part II, a separate group of 14 patients undergoing HF-HD via central venous catheters had measurement of activated partial thromboplastin time (aPTT) during the last hour of dialysis, as well as 15, 60, and 240 min after catheters were locked with 1:5000 heparin. The prescribed Kt/V was 1.74+/-0.31 for standard HD with heparin vs. 1.66+/-0.36 for HF-HD (p=ns). The delivered Kt/V was 1.42+/-0.32 vs. 1.36+/-0.38 (p=ns). Efficiency was 0.82 vs. 0.84 (p=ns). Baseline aPTT was 28+/-5 s, and increased to 126+/-54 s, 15 min after locking (p<0.0001) and to 71+/-50 s, 60 min after locking (p=0.005). By 240 min, the mean aPTT had fallen to 33+/-9 s (p=0.03), although individual values were still as high as 50 s. The HF technique does not compromise delivery of dialysis to inpatients. Increased treatment time is not necessary. Locking catheters with heparin after HF-HD resulted in prolonged unintentional anticoagulation.     

Does hemodiafiltration improve the removal of homocysteine?

High prevalence of hyperhomocysteinemia is common in hemodialysis (HD) patients and could contribute to worsen the cardiovascular risk. Beyond vitamin B status, dialysis modality itself could influence homocysteine (Hcy) levels. The objective was compare the reduction rate (RR) of Hcy and cysteine in stable dialyzed patients treated by standard HD or hemodiafiltration (HDF). Seventy‐five patients undergoing stable dialysis through standard high‐flux HD (n = 35) or HDF (n = 40) were included. Biological parameters were determined before and after a midweek dialysis session. Urea percent reduction per session and Kt/V index (K, body urea clearance, T, time of dialysis, and V, urea distribution volume), defined as a marker of dialysis efficacy, were similar between HD and HDF groups. By contrast, higher RR of beta2 microglobulin (β2m) was observed in HDF compared with HD (78.6 vs. 72.0%, respectively; P < 0.001). Likewise, higher RR of Hcy was obtained with HDF compared to HD (46.0 vs. 41.5%, respectively; P < 0.05), whereas the RR of cysteine was similar in both groups. Interestingly, a positive correlation between Hcy RR and urea Kt/V index was observed (r = 0.29, P < 0.05) and between Hcy RR and β2m RR (r = 0.45, P < 0.001). Time‐averaged concentration (TAC) of Hcy was lower with HDF compared with HD (17.8 vs. 19.1 μmol/L, respectively), although not significant. There was no difference in median Hcy according to dialysis modality for neither pre‐ nor postdialysis levels. Significant higher removal of Hcy was observed with HDF compared with standard HD, although urea Kt/V index was similar. Enhanced removal of middle molecules, such as β2m, could be involved in Hcy RR improvement with HDF.     

Comparisons of Kt/V evaluated using an online method and calculated from urea measurements in patients on intermittent hemodialysis

Kt/V(urea) (Kt/V) depends on the method applied for its evaluation. Our aim was to compare Kt/V obtained using the conductivity online method and that calculated from urea measurements. Studies were carried out in 40 patients. A stable dialysis schedule was maintained during the study. Online Kt/V was measured every week or 4 consecutive months. Single pool Kt/V (spKt/V) was calculated from urea estimations in the fourth week of the first month and in the last week of the fourth month of studies, using the formulas: (1)spKt/V = -ln(Ct/Co), where Ct is the postdialysis urea concentration obtained at the end of dialysis, Co the predialysis urea concentration obtained before the start of the blood pump; (2)spKt/V = -ln(R - 0.008 x t - f x UF/W), where R is the Ct/Co, t the duration of HD session, f=1.0, UF is the ultrafiltration volume (l), W is the body weight after the HD session; and (3)spKt/V + -ln(R - 0.008 x t) + (4 - 3.5 x R) x UF/W. The equilibrated Kt/V (eKt/V) was calculated as (3)spKt/V - {0.47 x [(3)spKt/V]/t} + 0.02. Correlation analysis was performed between all obtained Kt/V. Weekly online Kt/V was stable during 4 months of studies. In the first month, the respective values of online Kt/V, (1)spKt/V, (2)spKt/V, (3)spKt/V, and eKt/V were 1.15+/-0.14, 1.16+/-0.14, 1.38+/-0.17, 1.36+/-0.20, and 1.22+/-0.13. In the fourth month, these values were 1.17+/-0.14, 1.16+/-0.17, 1.38+/-0.22, 1.35+/-0.20, and 1.22+/-0.18. The respective values of Kt/V, estimated in the first and fourth month, were not different and showed a positive correlation: the highest one occurred between online Kt/V estimated at the indicated study periods (r=0.713, p=0.0000). Online Kt/V was significantly lower than (2)spKt/V, (3)spKt/V, and eKt/V. Correlation coefficients between online Kt/V, spKt/V, and urea reduction ratio did not exceed 0.490. Our studies show that Kt/V obtained using online monitoring indicates a lower intermittent hemodialysis adequacy that those calculated from urea measurements. This difference has to be remembered in application of results to clinical practice.     

Measurement of Hemodialysis Adequacy in a Changing World

Defining adequacy of dialysis remains an elusive goal. The application of the Kt/V_urea concept to clinical dialysis was a major improvement in trying to define a dialysis dose. Intuitively, the Kt/V concept makes a great deal of sense: the urea clearance of the dialyzer during dialysis (K), multiplied by the time (t) of dialysis, divided by the patient's urea distribution volume (V) ought to give the best number to compare the efficiency of dialyses that patients receive. There are, however, many pitfalls associated with the whole Kt/V_urea concept.     

Superior patient and technique survival with very high standard Kt/V in quotidian home hemodialysis

We studied the association of patient and dialysis factors with patient and technique survival in a cohort of all of our 191 of patients surviving >3 months on quotidian home hemodialysis (QHHD). Eighty‐one patients were on nocturnal QHHD and 110 on short ‐daily QHHD. Weekly dialysis time was 7.5–48 hours, single pool Kt/V was 0.38–4.5 per treatment, and weekly standardKt/V was 2.1–7.5. The association of 18 patient and dialysis variables with patient and technique survival was analyzed by Kaplan‐Meier and Cox analyses. Ninety‐nine patients (52%) remained on QHHD, 34 (18%) were transplanted, 31 (16%) returned to 3/week HD, and 27 (14%) died. The 5‐year patient survival was 71% ± 6% (night: 79% ± 7%, day: 69% ± 9%, P = 0.002). The 5‐year technique survival was 80% ± 4% (night: 93% ± 3%, day: 46% ± 17%, P = 0.001). In Cox analyses, patient survival was independently associated with standard Kt/V (hazard ratio [HR] = 0.29, P < 0.0001), graduating from high school (HS) (HR = 0.11, P = 0.0002), and use of graft/fistula (HR = 0.22, P = 0.007). Technique survival was independently associated with standard Kt/V (HR = 0.50, P = 0.0003) and start of QHHD after 2003 (HR = 0.18, P = 0.007). Every increase in standard Kt/V was associated with improved survival. The highest survival occurred when standard Kt/V exceeded 5.1, only possible when weekly dialysis hours exceed 35 hours. In QHHD, higher standard Kt/V, education, and subcutaneous access are associated with better patient survival and higher standard Kt/V and longer experience of center with better technique survival. There was no upper limit of standard Kt/V, where survival plateaus. The amount of minimally “adequate” dialysis should be much increased.     

Inherent Errors in the Quantitation of Dialysis Delivery: Implications For CAPD and Daily Hemodialysis

When compared to intermittent dialysis, the theoretical advantages of continuous dialysis may be less important than its practical disadvantage: the inability to accurately quantify dialysis. With intermittent dialysis the change in blood urea nitrogen over the course of the treatment allows the ratio of K (urea clearance) to V (volume of distribution of urea or total body water) to be determined, hence an accurate Kt/V. In continuous dialysis this approach cannot be used due to the steady-state nature of blood urea levels. Instead, V is estimated, generally from the Watson equations. This estimate has sufficient inaccuracy to result in substantial unrecognized underdialysis in many patients.     

Quantitating Dialysis in the Home Hemodialysis Patient: A Simple and Practical Approach

Home hemodialysis is the most cost-effective form of dialysis and is associated with the lowest mortality. Home hemodialysis patients are usually highly motivated, independent, and actively employed. Because of the minimal supervision they require and the fact that they are not in a controlled environment, it is easy to overlook the measurement of their dialysis adequacy. We studied 6 home hemodialysis patients and demonstrated that blood urea measured 30 min before the end of dialysis (Ct-30) is equivalent to that measured 30 min after the end of dialysis (Ct+30). The Kt/V results using Ct-30, Kt/V(Ct-30), were almost equivalent to Kt/V(Ct+30) (p = 0.5). The Kt/V Kt/V(Ct) using blood urea measured at the end of dialysis (Ct) significantly overestimated Kt/V(Ct-30) and Kt/V(Ct+30) (p = 0.007) The calculated percent reduction of urea (PRU) was about 5% less when using Ct-30 compared with Ct (p = 0.001). Taking blood samples 30 min before the end of dialysis for urea kinetics is more convenient for the home dialysis patients, since no other technical aspects of dialysis need their attention. The samples can be delivered to the laboratory the following day, because the blood may be stored in heparinized tubes at 4°C without deterioration of urea and creatinine concentrations. The Kt/V(Ct-30) was almost equal to Kt/V(Ct+30), so there is no longer any concern for the errors introduced by urea rebound. The blood pump must be reduced to 80 mL/min for about 10 sec to eliminate the errors due to fistula and cardiopulmonary recirculation. A simple programmable calculator will facilitate the calculation of accurate results using the Daugirdas second-generation formula.     

The efficiency of potassium removal during bicarbonate hemodialysis

Patients on chronic hemodialysis often portray high serum [K+]. Although dietary excesses are evident in many cases, in others, the cause of hyperkalemia cannot be identified. In such cases, hyperkalemia could result from decreased potassium removal during dialysis. This situation could occur if alkalinization of body fluids during dialysis would drive potassium into the cell, thus decreasing the potassium gradient across the dialysis membrane. In 35 chronic hemodialysis patients, we compared two dialysis sessions performed 7 days apart. Bicarbonate or acetate as dialysate buffers were randomly assigned for the first dialysis. The buffer was switched for the second dialysis. Serum [K+], [HCO3-], and pH were measured in samples drawn before dialysis; 60, 120, 180, and 240 min into dialysis; and 60 and 90 min after dialysis. The potassium removed was measured in the dialysate. During the first 2 hr, serum [K+] decreased equally with both types of dialysates but declined more during the last 2 hr with bicarbonate dialysis. After dialysis, the serum [K+] rebounded higher with bicarbonate bringing the serum [K+] up to par with acetate. The lower serum [K+] through the second half of bicarbonate dialysis did not impair potassium removal (295.9 +/- 9.6 mmol with bicarbonate and 299.0 +/- 14.4 mmol with acetate). The measured serum K+ concentrations correlated with serum [HCO3-] and blood pH during bicarbonate dialysis but not during acetate dialysis. Alkalinization induced by bicarbonate administration may cause redistribution of K during bicarbonate dialysis but this does not impair its removal. The more marked lowering of potassium during bicarbonate dialysis occurs late in dialysis, when exchange is negligible because of a low gradient.     

Survival with short‐daily hemodialysis: Association of time,site, and dose of dialysis

In thrice‐weekly hemodialysis, survival correlates with the length of time (t) of each dialysis and the dose (Kt/V), and deaths occur most frequently on Mondays and Tuesdays. We studied the influence of t and Kt/V on survival in 262 patients on short‐daily hemodialysis (SDHD) and also noted death rate by weekday. Contingency tables, Kaplan‐Meier analysis, regression analysis, and stepwise Cox proportional hazard analysis were used to study the associations of clinical variables with survival. Patients had been on SDHD for a mean of 2.1 (range 0.1–11) years. Mean dialysis time was 12.9 ± 2.3 h/wk and mean weekly stdKt/V was 2.7 ± 0.5. Fifty‐two of the patients died (20%) and 8‐year survival was 54 ± 5%. In an analysis of 4 groups by weekly dialysis time, 5‐year survival continuously increased from 45 ± 8% in those dialyzing <12 hours to 100% in those dialyzing >15 hours without any apparent threshold. There was no association between Kt/V and survival. In Cox proportional hazard analysis, 4 factors were independently associated with survival: age in years Hazard Ratio (HR)=1.05, weekly dialysis hours HR=0.84, home dialysis HR=0.50, and secondary renal disease HR=2.30. Unlike conventional HD, no pattern of excessive death occurred early in the week during SDHD. With SDHD, longer time and dialysis at home were independently associated with improved survival, while Kt/V was not. Homedialysis and dialysis 15+ h/wk appear to maximize survival in SDHD.     

Continuous online monitoring of ionic dialysance allows modification of delivered hemodialysis treatment time

Considerable intrinsic intrapatient variability influences the actual delivery of Kt/V. The aim of this study is to examine the feasibility of using continuous online assessment of ionic dialysance measurements (Kt/V(ID)) to allow dialysis sessions to be altered on an individual basis. Ten well-established chronic hemodialysis (HD) patients without significant residual renal function were studied (mean age 65+/-4.3 [38-81] years, mean length of time on dialysis 66+/-18 [14-189] months). These patients had all been receiving thrice-weekly 4-hr dialysis using Integra dialysis monitors. Dialysis monitors were equipped with Diascan modules permitting measurement of Kt/V(ID). Predicted treatment time required to achieve a Kt/V(ID) > or = 1.1 (equivalent to a urea-based method of 1.2) was calculated from the delivered Kt/V(ID) at 60 and 120 min. Treatment time was reprogrammed at 2 hr (ensuring all planned ultrafiltration would be accommodated into the new modified session duration). Owing to practical issues, and to avoid excessively short dialysis times, these changes were censored at no more than+/-10% of the usual 240-min treatment time (210-265 min). Data were collected from a total of 50 dialysis sessions. Almost all sessions (47/50) required modification of the standard treatment time: 13/50 sessions were lengthened and 34/50 shortened (mean length of session 232.2+/-2.5 [210-265] min). A Kt/V(ID) of > or = 1.1 was achieved in 39/50 sessions. The difference in mean urea-based Kt/V poststudy (1.3+/-0.05 [1.1-1.6]) and mean achieved Kt/V(ID) (1.16+/-0.02 [0.7-1.37]) was significant (p = 0.002). The use of individualized variable dialysis treatment time using online ionic dialysance measurements of Kt/V(ID) appears both practicable and effective at ensuring consistently delivered adequate dialysis.     

Influence of sodium profile in preventing complications during hemodialysis

Although a safe procedure, hemodialysis (HD) can cause numerous complications. The objective of this study was to evaluate the incidence of complications during dialysis, interdialytic weight gain, and the predialysis and postdialysis blood pressure in HD patients with and without variable sodium. Patients were observed during 12 HD sessions and those presenting with recurrent hypotension were selected for a step-wise model of variable sodium profiling. A total of 53 patients were evaluated; the mean-SD age was 53.7+/-16.3 years and 22 (41.5%) were male. Of these, 18 (34.0%) were selected to receive variable sodium profiling: the mean (SD) age was 59.9+/-12.6 years, and 10 (55.6%) were female. A significant decline in the occurrence of cramps (p<0.027), in the mean interdialytic weight gain (p<0.009), and a tendency to reduce the number of hypotensive episodes were detected in patients using variable sodium profiling. On the other hand, predialysis systolic blood pressure presented a significant increase (p<0.048). Using variable sodium, there was a statistically significant reduction in cramps and in the mean interdialytic weight gain. There was a significant increase in predialysis systolic pressure. Regarding hypotension episodes, only a tendency toward a reduction in the frequency of hypotension episodes could be detected.     

Daily Hemodialysis versus Standard Hemodialysis: TAC,TAD, Weekly eKt/V,std(Kt/V), and PCRn

Seven patients, mean age 42.57 ± 15.69 years (range 21 – 67 years), on standard hemodialysis (SHD), 4 – 5 hours, three times per week for 11.0 ± 6.63 years (range 1 – 18 years), were switched to daily hemodialysis (DHD), 2 – 2.5 hours, six times per week. For each type of treatment similar parameters were applied, and the total weekly time was the same. Mean duration of DHD was 15.4 ± 4.98 months (range 7 – 20 months). We report here our results of quantification in each method, including time-averaged concentration (TAC), normalized protein catabolic rate (PCRn), equilibrated Kt/V (eKt/V), equivalent normalized continuous standard clearance [std(Kt/V)], equivalent renal urea clearance (eKRn), and time-averaged deviation (TAD). With DHD, urea TAC was reduced from 19.09 ± 3.47 to 15.16 ± 3.21 mmol/L (p = 0.026), urea TAD diminished from 4.76 ± 1.04 to 2.52 ± 0.57 mmol/L (p = 0.000 53), PCRn increased from 1.11 ± 0.23 to 1.42 ± 0.24 g/kg/day (p = 0.001), weekly eKt/V increased from 4.11 ± 0.31 to 4.74 ± 0.43 (p = 0.000 25), std(Kt/V) rose from 2.17 ± 0.06 to 4.02 ± 0.25 (p = 0.0001), and eKRn increased from 12.96 ± 0.60 to 21.7 ± 3.09 mL/min (p = 0.000 45). On DHD the most important quantitative variation is the decrease of urea TAD (closer to that of a healthy kidney), due to the increased frequency of dialysis; std(Kt/V) practically doubled and represents 30% of that of normal renal function. These changes are probably the main explanation for the clinical improvements, but it is difficult to dissociate the effects of increased dialysis dose from the effects of decreased TAD.     

Correlates of ADL difficulty in a large hemodialysis cohort

Needing assistance with activities of daily living (ADL) is an early indicator of functional decline and has important implications for individuals' quality of life. However, correlates of need for ADL assistance have received limited attention among patients undergoing maintenance hemodialysis (HD). A multicenter cohort of 742 prevalent HD patients was assessed in 2009–2011 and classified as frail, prefrail and nonfrail by the Fried frailty index (recent unintentional weight loss, reported exhaustion, low grip strength, slow walk speed, low physical activity). Patients reported need for assistance with 4 ADL tasks and identified contributing symptoms/conditions (pain, balance, endurance, weakness, others). Nearly 1 in 5 patients needed assistance with 1 or more ADL. Multivariable analysis showed increased odds for needing ADL assistance among frail (odds ratio [OR] 11.35; 95% confidence interval [CI] 5.50–23.41; P < 0.001) and prefrail (OR 1.93; 95% CI 1.01–3.68; P = 0.046) compared with non‐frail patients. In addition, the odds for needing ADL assistance were lower among blacks compared with whites and were higher among patients with diabetes, lung disease, and stroke. Balance, weakness, and “other” (frequently dialysis‐related) symptoms/conditions were the most frequently named reasons for ADL difficulty. In addition to interventions such as increasing physical activity that might delay or reverse the process of frailty, the immediate symptoms/conditions to which individuals attribute their ADL difficulty may have clinical relevance for developing targeted management and/or treatment approaches.     

Gustatory sweating recurring on peritoneal dialysis but resolving during periods of hemodialysis

Gustatory sweating is a rare disorder characterized by profuse sweating on the forehead, face, scalp, and neck occurring soon after ingesting food, which has been reported in diabetic patients. The mechanism is thought to be triggered by taste buds and not gastric stimulation. We report a case where gustatory sweating repeatedly developed on peritoneal dialysis that resolved on periods of hemodialysis. A 32-year-old woman with diabetic end-stage renal disease developed gustatory sweating shortly after beginning continuous ambulatory peritoneal dialysis despite excellent clearances. After 5 months, she changed to hemodialysis for 2 months and noticed complete resolution of her gustatory sweating; however, after her return to peritoneal dialysis 2 months later, her gustatory sweating recurred. While on peritoneal dialysis, she was treated with clonidine, which resulted in improvement but not resolution of her symptoms as had occurred on hemodialysis. Another period on hemodialysis resulted in the resolution of her symptoms that returned again after restarting peritoneal dialysis. Clonidine provided incomplete relief while topical glycopyrrolate was effective and without complications. We report recurrent gustatory sweating on peritoneal dialysis that resolved with hemodialysis. We have no data to suggest that intra-abdominal stimulation played a role, but rather that despite excellent clearances neuropathy may have played a role. Treatment with topical glycopyrrolate may be safe and effective given every third day if clonidine is ineffective.     

Gender,low Kt/V,and mortality in Japanese hemodialysis patients: Opportunities for improvement through modifiable practices

Guidelines have recommended single pool Kt/V > 1.2 as the minimum dose for chronic hemodialysis (HD) patients on thrice weekly HD. The Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown that “low Kt/V” (<1.2) is more prevalent in Japan than many other countries, though survival is longer in Japan. We examined trends in low Kt/V, dialysis practices associated with low Kt/V, and associations between Kt/V and mortality overall and by gender in Japanese dialysis patients. We analyzed 5784 HD patients from Japan DOPPS (1999–2011), restricted to patients dialyzing for >1 year and receiving thrice weekly dialysis. Logistic regression models estimated the relationships of patient characteristics with Kt/V. Logistic models also were used to estimate the proportion of low Kt/V cases attributable to various treatment practices. Multivariable Cox regression was used to estimate the associations of low Kt/V, blood flow rate (BFR), and treatment time (TT), with all‐cause mortality. From 1999 to 2009, the prevalence of low Kt/V declined in men (37–27%) and women (15–10%). BFR <200 mL/min, TT <240 minutes, and dialyzate flow rate (DFR) < 500 mL/min were common (35, 13, and 19% of patients, respectively) and strongly associated with low Kt/V. Fifteen percent of low Kt/V cases were attributable to BFR <200 and 13% to TT <240, compared to only 3% for DFR <500. Lower Kt/V was associated with elevated mortality, more so among women (hazard ratio [HR] = 1.13 per 0.1 lower Kt/V, 95% CI: 1.07–1.20) than among men (HR = 1.06 per 0.1 lower Kt/V, 95% CI: 1.00–1.12). The relatively large proportion of low Kt/V cases in Japanese facilities may potentially be reduced 30% by increasing BFR to 200 mL/min and TT to 4 hours thrice weekly in HD patients. Associations of low Kt/V with elevated mortality suggest that modification of these practices may further improve survival for Japanese HD patients.     

Stability of nutritional parameters during a 5-year follow-up in patients treated with sequential long-hour hemodialysis

Progressive nutritional impairment has been recently reported during conventional hemodialysis (HD) treatment. We studied the nutritional parameters during a 5-year follow-up in HD patients. Thirty-three patients (15F/18M; 65 years old at the study start) filled out a 3-day food questionnaire once a year between 1995 and 1999 (study group). Twenty patients, who did not fill out the food records during this period served as a control group (control group). The food record was run by the renal dietician using a dedicated software, providing daily energy and protein intakes (DEI and DPI). Serum albumin, normalized protein equivalent of nitrogen appearance (nPNA), and postdialysis body weight (BW) at the time of food record were collected in the study group and from the patient chart in the control group. The energy intake in the study group and the protein intake in both groups were close to the recommended intakes in ESRD patients. Protein intake assessed from food questionnaire or from urea kinetics were not statistically different. Using ANOVA for repeated measures, no difference along the 5 years was found for daily energy intake, daily protein intake, nPNA, and BW in the study group. The BW and nPNA remained stable in the control group. Hence, this study does not confirm the progressive nutritional impairment reported in the HEMO study, whereas the patients' age and vintage are largely higher in the present study. The role of a large dialysis dose in maintaining nutritional status in HD patients is discussed.