Nightly Home Hemodialysis: Fifteen Months of Experience in Lynchburg,Virginia

What constitutes adequate dialysis has been debated in the nephrology literature over the past eight years. The mortality rate of patients on dialysis in the United States is about 20% per year. We believed that short and infrequent dialysis sessions contributed to poor outcomes. To improve the results, Lynchburg Nephrology started the nightly home hemodialysis (NHHD) program in September 1997. Ten patients were trained in the first 15 months of the program. Patients dialyzed 7 – 9 hours, 6 nights/week, using the Fresenius 2008H machine. A standard dialysis solution with 2.0 mEq/L potassium, calcium concentration of 3.0 – 3.5 mEq/L was used. Dialysis solution flow rates were 200 – 300 mL/min. Serum phosphate levels were maintained above 2.5 mg/dL by adding 0 – 45 mL Fleet's Phosphosoda to the bicarbonate bath. Patients had marked improvement in quality of life as measured with the SF-36. Blood pressure was better controlled with fewer medications. All phosphate binders were eliminated. Caloric intake and protein intake increased to normal levels as measured by three-day dietary histories pre-NHHD, and at 3, 6, and 12 months on NHHD. Epoetin alfa dosages were reduced by about 50%. Nightly home hemodialysis should be considered as a valuable modality option for end-stage renal disease patients; it is potentially superior to conventional thrice-weekly hemodialysis.     

Nightly home hemodialysis: Five and one-half years of experience in Lynchburg, Virginia

Background: Lynchburg Nephrology Dialysis Incorporated initiated a nightly home hemodialysis (NHHD) program in September 1997. As of April 30, 2003, 40 patients had completed training; 28 patients were at home and 2 patients were in training. The average age of the patients at the initiation of the home‐based therapy was 50 years, with a range of 23 to 81 years. There have been 24,239 treatments at home with a total of 84.86 patient‐years on NHHD, the longest patient for 66.7 months and the shortest for 1 month. Methods: Patients dialyzed using the Fresenius 2008H machine, 6 to 10 hr, 5 to 6 nights per week. Treatment parameters included a blood flow rate of 200 to 250 mL/min; a dialysis flow rate of 200 to 300 mL/min; and a standard dialysis solution with 2.0 mEq/L potassium, 3.0 to 3.5 mEq/L calcium concentrations, 35 mEq/L HCO₃, and 140 mEq/L sodium. The longitudinal data of each patient in the program for 1, 2, 3, 4, and 5 years were compared to the same patient's pre‐NHHD data. There were 25 patients in the program for 1 year, 19 patients for 2 years, 14 patients for 3 years, 6 patients for 4 years, and 4 patients for 5 years. Results: Statistically significant improvement occurred in all five groups' need for antihypertensive medications and phosphate binders, SF36 scores, calcium/phosphorus product, blood pressure, number of hospital admissions, and number of days of stay in the hospital. The mortality rate was 2.4% deaths per patient‐year with a 95% confidence interval of 0.9% to 9.4%. Conclusions: In a longitudinal study, NHHD showed significant improvements in patient secondary outcomes. The improvement in these secondary outcomes was associated with an improvement in mortality rate.     

Calcium‐phosphate and parathyroid intradialytic profiles: A potential aid for tailoring the dialysate calcium content of patients on different hemodialysis schedules

Severe hyperparathyroidism is a challenge on hemodialysis. The definition of dialysate calcium (Ca) is a pending issue with renewed importance in cases of individualized dialysis schedules and of portable home dialysis machines with low‐flow dialysate. Direct measurement of calcium mass transfer is complex and is imprecisely reflected by differences in start‐to‐end of dialysis Ca levels. The study was performed in a dialysis unit dedicated to home hemodialysis and to critical patients with wide use of daily and tailored schedules. The Ca‐phosphate (P)‐parathyroid hormone (PTH) profile includes creatinine, urea, total and ionized Ca, albumin, sodium, potassium, P, PTH levels at start, mid, and end of dialysis. “Severe” secondary hyperparathyroidism was defined as PTH > 300 pg/mL for ≥3 months. Four schedules were tested: conventional dialysis (polysulfone dialyzer 1.8–2.1 m²), with dialysate Ca 1.5 or 1.75 mmol/L, NxStage (Ca 1.5 mmol/L), and NxStage plus intradialytic Ca infusion. Dosages of vitamin D, calcium, phosphate binders, and Ca mimetic agents were adjusted monthly. Eighty Ca‐P‐PTH profiles were collected in 12 patients. Serum phosphate was efficiently reduced by all techniques. No differences in start‐to‐end PTH and Ca levels on dialysis were observed in patients with PTH levels < 300 pg/mL. Conversely, Ca levels in “severe” secondary hyperparathyroid patients significantly increased and PTH decreased during dialysis on all schedules except on Nxstage (P < 0.05). Our data support the need for tailored dialysate Ca content, even on “low‐flow” daily home dialysis, in “severe” secondary hyperparathyroid patients in order to increase the therapeutic potentials of the new dialysis techniques.     

Phosphorus Clearance Using Two Hemodialyzers Placed in Parallel

Control of hyperphosphatemia is a major goal in patients with end‐stage renal disease. However, removal of retained inorganic phosphorus during hemodialysis remains a major problem. We compared clearances and total phosphate removal in large patients treated with two F‐80 dialyzers (Fresenius Medical Care of North America, Lexington, MA, U.S.A.) placed in parallel, and small patients dialyzed with a single F‐80 dialyzer (SD). Clearances were obtained using total dialysate collections. Eight dialysate collections (5 patients) using double parallel dialyzers (DD group) were compared with 5 dialysate collections (4 patients) using single dialyzers (SD group). Blood and dialysate flow rates and time of dialysis treatment were identical between the groups. The DD group's Kt/V _urea was 1.46 ± 0.13; SD group's Kt/V _urea was 1.35 ± 0.09 (p = 0.2). Absolute phosphorus removal was 1594 ± 300 mg for the DD group, compared to 1108 ± 285 mg in the SD group (p = 0.03). Urea clearance in the DD group was 285 ± 25 mL/minute and 251 ± 27 mL/ min in the SD group (p = 0.082). Phosphorus clearance was 178 ± 32 mL/min in the DD group and 149 ± 38 mL/min in the SD group (p = 0.039). There was no correlation between phosphorus clearance and dialyzer reuse. The bulk of phosphorus removal was achieved during the first 2 hours of hemodialysis. This finding is consistent with the hypothesis that there are at least two pools of body phosphorus. Using hemodialyzers placed in parallel led to higher phosphate clearance and total phosphorus removal. This higher phosphate removal may be related in part to increasing the concentration gradient for transfer out of a second compartment.     

Pilot study to assess increased dialysis efficiency in patients with limited blood flow rates due to vascular access problems

In the last few years, the number of hemodialysis patients with inadequate blood flow (Qb) rates has increased due to vascular access problems. To avoid a clinical status of underdialysis, these patients need long-lasting dialysis sessions. However, other factors aimed to optimize the dialysis dose have to be considered. High-efficiency convective therapies, such as online hemodiafiltration (HDF), are claimed to be superior to high-flux hemodialysis (HF-HD) in improving the dialysis efficacy, but treatment efficacy is strongly related to blood flow rate and infusion volumes. Online mid-dilution (HDF-MD) with the Nephros OL-pure MD190 represents a new HDF concept to increase the removal of middle molecules. In a cross-over clinical trial, 8 patients, with Qb eff <300 mL/min, received either online HDF-MD or HF-HD; Qd was 700 mL/min, the time duration was 240 min, and the filtration volume in HDF-MD was 112+/-7 mL/min. No differences were found for Kt/V, urea, and creatinine clearances. Clearance of both small phosphate (P) large beta(2)-microglobulin (beta(2)m), and leptin (L) solutes was significantly greater for MD (P 217+/-32, beta(2)m 85.5+/-10, L 42.6+/-18 mL/min) than for HF-HD (P 178+/-32, beta(2)m 71.9+/-13, L 32.1+/-12 mL/min). The results of this study indicate that HDF remains the best means of providing increased removal of large-molecular weight solutes even in patients with vascular access problems.     

Normalization of Dialysis Dose for Daily Dialysis

The equilibrated Kt/V (eKtV) is widely used in hemodialysis (HD) as a measure of the intensity (magnitude) of an individual dialysis treatment. Adequate eKt/V for thrice‐weekly hemodialysis (twHD) has been extensively studied, and a value in the range 1.0 – 1.1 per treatment (3.0 – 3.3 weekly) is generally considered to represent adequate therapy for this specific frequency of dialysis. However, for other schedules, summing eKt/V's and time‐averaging the clearance is not appropriate. This was first demonstrated several years ago by the observation that a weekly eKt/V of 2.0 in continuous ambulatory peritoneal dialysis (CAPD) is therapeutically equal to a weekly eKt/V of 3.0 in twHD. That paradox has been resolved by the standard Kt/V (stdKt/V), which accounts for the first order nature of solute removal by dialysis, and which correctly predicts a normalized weekly stdKt/V of 2.0 for both CAPD and twHD. The equivalent renal clearance (EKR) has also been advanced as a method to normalize dose for varying treatment schedules. However, mathematical consideration shows that EKR is an exact time‐averaged clearance. Analysis of data reported for daily dialysis by Piccoli et al. in the present issue of Hemodialysis International shows that the EKR_ct/V calculated for daily dialysis is identical to the sum of eKt/V's for the individual dialyses. We therefore conclude that EKR is not a suitable parameter for normalizing the dialysis dose, because it fails to reflect the effect of dialysis frequency in HD therapy.     

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.     

Barriers to access before initiation of hemodialysis: a single-center review

Guidelines recommend that > or =50% of patients starting dialysis have a fistula. We reviewed our experience in consecutive incident patients over a 1-year period. Only 30 of the 93 patients starting hemodialysis had a fistula that was accessed. Late referral (nephrology contact <90 days) was a significant issue in 48% (30/63) of the patients without a fistula. Most (n=21) of the late referrals were acute disease; only 9 were late referrals of chronic disease. Nephrology follow-up exceeded 200 days in the remaining (33/63) without this access. In the cohort with sufficient nephrology referral, we explored variables associated with a fistula (n=30) compared with those without one (n=33). In multivariate logistic regression analysis, peripheral vascular disease (odds ratio [OR] 0.026, 95% confidence interval [CI] 0.002-0.286) and rapid loss of estimated glomerular filtration rate (eGFR) (OR 0.745 per mL/min/1.73 m(2)/year, 95% CI 0.625-0.888) in the year preceding dialysis were significant negative predictors for a fistula. Patients without access experienced faster declines in GFR in the year preceding dialysis (12.1+/-9.9 vs. 4.7+/-3.5 mL/min 1.73 m(2) with access, p<0.001). Glomerular filtration rate loss in the 2 years before starting dialysis was the same between the 2 groups (-0.54+/-10.4 vs. 1.42+/-3.9 mL/min 1.73 m(2)). Age, sex, diabetes, other comorbidity, length of nephrology follow-up, eGFR at dialysis start, hemoglobin, and albumin were not significant. At our center, rapid loss of renal function in otherwise stable chronic kidney disease (CKD) patients is more important than late referral of CKD for the lack of access. Improvements in rapid referral for access creation could help reduce this barrier.     

Higher arteriovenous fistulae blood flows are associated with a lower level of dialysis-induced cardiac injury

Native arteriovenous fistulae (AVF) remain the vascular access of choice for hemodialysis (HD). Despite being associated with superior long-term outcomes (cf. catheter use), little is known about the systemic hemodynamic consequences of AVFs. Repetitive myocardial injury (myocardial stunning) is an under-recognized common consequence of HD. The aim of this study was to examine the impact of AVF flow (Qa) on dialysis-induced cardiac injury. We studied 50 chronic HD patients. All patients underwent echocardiography (and subsequent quantitative offline analysis) at baseline, during and post dialysis, to assess left ventricular function and the development of regional wall motion abnormalities. Qa was measured using ionic dialysance. Patients were divided into Qa tertiles (<500, mean 291±101 mL/min, 500–1000, mean 739±130 mL/min and >1000, mean 1265±221 mL/min). There were no significant differences between the groups in terms of age, sex, diabetes, or resting ejection fraction. Patients with Qa>1000 mL/min had a lower prevalence of left ventricular hypertrophy (55% vs. 76%, P=0.01). Dialysis-induced myocardial stunning (seen in 65% of the patients studied) was significantly and sequentially reduced in those patients with higher Qas. This was seen in a lower number of segments and ventricular regions developing regional wall motion abnormalities, as well as a significantly reduced mean and cumulative percentage reduction in fractional shortening of those ventricular segments affected (−187±37%, −161±26%, and −101±25%, respectively, P=0.04). Relatively higher AVF flows appear to be associated with a lower level of observed HD-induced cardiac injury.     

Daily (quotidian) nocturnal home hemodialysis: Nine years later

Daily nocturnal home hemodialysis was developed to satisfy the need for a highly effective, smooth, and cost‐effective home dialysis therapy. It combines the benefits of the following dialysis methods: long, frequent, and home hemodialysis. It provides a high dialysis dose for small, as well as large, molecules including β₂‐microglobulin; improves quality if life; and leads to control of hyperphosphatemia without the need for phosphate binders, as well as dissolution for extraosseous calcifications. Furthermore, it controls blood pressure often without medications, is associated with regression of left ventricular hypertrophy, improves cardiac function, improves anemia as well as nutrition, allows an unrestricted diet, and corrects sleep apnea. Finally, it decreases the overall cost of patient care and improves cost utility when compared to conventional hemodialysis. The main obstacle to its wider utilization is the structure of the current reimbursement system. Along with short daily hemodialysis, long intermittent dialysis, and the convective dialysis techniques, daily nocturnal hemodialysis promises to improve dialysis outcomes.     

Management of hypophosphatemia in nocturnal hemodialysis with phosphate-containing enema: a technical study

Hypophosphatemia is observed in patients undergoing nocturnal hemodialysis. Phosphate is commonly added to the dialysate acid bath, but systematic evaluation of the safety and reliability of this strategy is lacking. The objectives of this study were 4‐fold. First, we determined whether predictable final dialysate phosphate concentrations could be achieved by adding varying amounts of Fleet^® enema. Second, we assessed the stability of calcium (Ca) and phosphate dialysate levels under simulated nocturnal hemodialysis conditions. Third, we assessed for Ca‐phosphate precipitate. Finally, we evaluated whether dialysate containing Fleet^® enema met the current sterility standards. We added serial aliquots of enema to 4.5 L of dialysate acid concentrate and proportioned the solution on Gambro and Althin/Baxter dialysis machines for up to 8 hours. We measured dialysate phosphate, Ca, pH, and bicarbonate concentrations at baseline, and after simulated dialysis at 4 and 8 hours. We evaluated for precipitation visually and by assessing optical density at 620 nm. We used inoculation of agar to detect bacteria and Pyrotell reaction for endotoxin. For every 30 mL of Fleet^® (1.38 mmol/mL of phosphate) enema added, the dialysate phosphate concentration increased by 0.2 mmol/L. There were no significant changes in dialysate phosphate, Ca, pH, and bicarbonate concentrations over 8 hours. No precipitate was observed in the dialysate by optical density measures at 620 nm for additions of up to 90 mL of enema. Bacterial and endotoxin testing met sterility standards. The addition of Fleet^® enema to dialysate increases phosphate concentration in a predictable manner, and no safety problems were observed in our in vitro studies.     

Catheter lock heparin concentration: effects on tissue plasminogen activator use in tunneled cuffed catheters

The optimal cost-effective heparin concentration for locking tunneled cuffed hemodialysis catheters (TCC) is unclear. We performed a retrospective review of tissue plasminogen activator (tpa) use in TCC in 2 hemodialysis units that used different heparin concentrations for TCC lock to evaluate the effectiveness of lower dose heparin as a lock for TCC. Catheter blood flow rate per treatment, units of heparin given during treatments, patient hemoglobin values and use of warfarin, and tpa use were compared for all patients using TCC for at least 3 months in 2 in-center hemodialysis units between 11/04 and 5/05. Both units used the same type of catheters and biocompatible, non-re-use dialyzers. Unit A used heparin 1000 U/mL for catheter locks, and Unit B used heparin 10,000 U/mL for catheter locks. Twelve of 19 Unit A patients, tpa and 14 of 45 Unit B patients received intracatheter during the study period (p=0.0009). There were no differences in the number of patients on warfarin, treatment blood flow rate, or mean hemoglobin levels between the 2 groups. The mean heparin units given during hemodialysis treatments was higher in Unit A patients (3.92+/-2.2 vs. 3.83+/-2.5 1000 U, p=0.05). Assuming a 4.1 mL total catheter lumen volume, the cost of heparin 1000 U/mL lock was 0.20 dollars per treatment and heparin 10,000 U/mL cost 2.67 dollars/treatment; tpa cost 89.02 dollars/use. Using the 10,000 U/mL heparin as a catheter lock was associated with less frequent use of tpa. However, the significantly lower cost of the 1000 U/mL heparin could result in significant savings despite higher tpa use. This retrospective, uncontrolled study of a small number of patients suggests that comparing low and high heparin concentrations as a TCC lock would be worthwhile. Prospective studies would be helpful to define the most appropriate and cost-effective lock for TCC.     

Low dose heparin lock (1000 U/mL) maintains tunnelled hemodialysis catheter patency when compared with high dose heparin (5000 U/mL): A randomised controlled trial

Introduction Heparin is commonly used after hemodialysis treatments as a locking solution to prevent catheter thrombosis. The comparative efficacy and safety of different heparin concentrations to maintain catheter patency has been previously reported in retrospective studies. We conducted a prospective, randomised, controlled study of 1000 U/mL heparin (low dose) versus 5000 U/mL heparin (high dose) locking solution to maintain patency of tunnelled catheters. Methods One hundred patients receiving chronic, unit‐based hemodialysis with newly placed tunnelled hemodialysis catheters (less than 1 week) were randomly assigned to either a low dose (n = 48) or high dose heparin (n=52). The primary intention‐to‐treat analysis examined time to malfunction in both groups over a 90 day period. A secondary analysis compared baseline patient characteristics in relation to catheter malfunction. Findings Overall rate of catheter patency loss was 32% of catheters by 90 days. There was no significant difference in time to malfunction of catheters locked with low dose or high dose heparin (P = 0.5770). Time to catheter malfunction was not associated with diabetic, hypertensive or smoking status. There was no difference in mean delivered blood flow rate, venous and arterial pressure, and dialysis adequacy between low dose and high dose groups. No patient suffered a hemorrhagic complication requiring hospitalisation during the study period. Discussion Low dose heparin is adequate to maintain tunnelled hemodialysis catheter patency when compared with high dose heparin. The study also suggests that there is no relationship between catheter malfunction and diabetic, hypertensive or smoking status.     

The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: A qualitative study

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end‐stage kidney disease in Australian Aboriginal people is eight times higher than non‐Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the “costly” crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family‐focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal‐led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.     

The prevalence of intestinal parasites in hemodialysis patients in Bushehr,Iran

Hemodialysis patients, due to a dysfunction of the immune response, are prone to a variety of opportunistic infections. Studies of intestinal parasitic infections in these patients are limited. Therefore, the present study was performed to determine the prevalence of these infections in patients on hemodialysis in Bushehr. In this cross‐sectional study, fecal samples have been collected from all hemodialysis patients who were continuously referred from September 2011 to September 2012 to the dialysis center at Bushehr and tested using routine parasitological methods. From a total of 88 patients studied, 25 patients (28.4%) were infected with one or more intestinal parasites. Blastocystis hominis and Entamoeba coli with 13.6% and 6.7% prevalence had the highest prevalence among the patients, respectively. The age group 51–70 years had the highest rates of infection. Statistical analysis showed no relationship between sex and the risk of intestinal parasites. Seventeen percent of infected patients showed up with diarrhea and this relationship was statistically significant. Considering the high prevalence of intestinal parasitic infection among hemodialysis patients in Bushehr and also the high probability of infection in these patients, it is recommended that periodic examinations and screening patients during dialysis and before kidney transplantation should be a part of routine medical care.     

Clinical use of high-efficiency hemodialysis treatments: long-term assessment

Significant technological changes in blood flow rate, dialyzer membrane permeability, bicarbonate dialysate, and ultrafiltration-controlled delivery systems permitted the implementation of 3 modifications to conventional hemodialysis as follows: high-efficiency hemodialysis (HEHD), high-flux hemodialysis (HFHD), and double-high-flux hemodiafiltration (HDF). The impact of these techniques on the quantity of the treatment administered and treatment time were assessed. One hundred and eighty-three patients were enrolled over 6 years. Monthly Kt/Vurea and dialysis treatment time were compared among the treatment techniques. In vivo extracorporeal clearances were measured for the dialyzers used. In vivo kinetically derived effective dialyzer clearances were calculated from Kt/V. Patient survival and standardized mortality ratio (SMR) were determined for each treatment modality. Treatment time averaged 192+/-28, 176+/-29, and 159+/-32 min, Kt/Vurea averaged 1.33+/-.34, 1.29+/-.30, 1.41+/-.32, and in vivo delivered urea clearance averaged 222+/-51, 272+/-34, and 333+/-43 mL/min for HEHD, HFHD, and HDF, respectively. These results were achieved even in patients with body weights in excess of 80 kgs. Net ultrafiltration rate during the treatment reached 20-30 mL/min, without clinical untoward effects. Blood flow rate ranged between 450-650 mL/min in all patients. Kaplan-Meier Survival analysis yielded a significant difference when high-efficiency treatments were compared with USRDS outcomes. Standardized mortality ratio analysis showed significance for only HDF vs. USRDS. High-efficiency treatments can provide the same quantity of treatment in a shorter period of time without affecting mortality. The increased spectrum of solutes removal provided by HFHD and HDF may be a further advantage of these treatments.     

Intensive weight loss combining flexible dialysis with a personalized,ad libitum,coach‐assisted diet program. A “pilot” case series

Obesity is a growing problem on dialysis. The best approach to weight loss has not been established. The risks of malnutrition may offset the advantages of weight loss. Personalized hemodialysis schedules, with an incremental approach, are gaining interest; to date, no studies have explored its potential in allowing weight loss. This case series reports on combining flexible, incremental hemodialysis, and intensive weight loss. Setting: a small Dialysis Unit, following incremental personalized schedules (2–6 sessions/week, depending on residual function), tailored to an equivalent renal clearance >12 mL/min. Four obese and two overweigh patients (5 male, 1 female; age: 40–63 years; body mass index [BMI] 31.1 kg/m²) were enrolled in a coach‐assisted weight loss program, with an “ad libitum” approach (3–6 foods/day chosen on the basis of their glycemic index and glycemic load). The diet consists of 8 weeks of rapid weight loss followed by 8–12 weeks of maintenance; both phases can be repeated. This study measures weight loss, side effects, and patients' opinions. Over 12–30 months, all patients lost weight (median ?10.3 kg [5.7–20], median ΔBMI–3.2). Serum albumin (pre‐diet 3.78; post‐diet 3.83 g/dL), hemoglobin (pre‐diet 11; post‐diet 11.2 g/dL), and acid–base balance (HCO₃ pre‐diet: 23.3; post‐diet: 23.4 mmol/L) remained stable, with decreasing needs for erythropoietin and citrate or bicarbonate supplements. Calcium‐phosphate‐parathyroid hormone (PTH) balance improved (PTH‐pre 576; post 286 pg/mL). Three out of 4 hypertensive patients discontinued, 1 decreased antihypertensives. None experienced severe side effects. Patient satisfaction was high (9 on a 0–10 analog scale). Personalized, incremental hemodialysis schedules allow patient enrollment in intensive personalized weight loss programs, with promising results.     

Solute kinetics with short-daily home hemodialysis using slow dialysate flow rate

"NxStage System One^™" is increasingly used for daily home hemodialysis. The ultrapure dialysate volumes are typically between 15 L and 30 L per dialysis, substantially smaller than the volumes used in conventional dialysis. In this study, the impact of the use of low dialysate volumes on the removal rates of solutes of different molecular weights and volumes of distribution was evaluated. Serum measurements before and after dialysis and total dialysate collection were performed over 30 times in 5 functionally anephric patients undergoing short-daily home hemodialysis (6 d/wk) over the course of 8 to 16 months. Measured solutes included β₂ microglobulin (β₂M), phosphorus, urea nitrogen, and potassium. The average spent dialysate volume (dialysate plus ultrafiltrate) was 25.4±4.7 L and the dialysis duration was 175±15 min. β₂ microglobulin clearance of the polyethersulfone dialyzer averaged 53±14 mL/min. Total β₂M recovered in the dialysate was 106±42 mg per treatment (n=38). Predialysis serum β₂M levels remained stable over the observation period. Phosphorus removal averaged 694±343 mg per treatment with a mean predialysis serum phosphorus of 5.2±1.8 mg/dL (n=34). Standard Kt/V averaged 2.5±0.3 per week and correlated with the dialysate-based weekly Kt/V. Weekly β₂M, phosphorus, and urea nitrogen removal in patients dialyzing 6 d/wk with these relatively low dialysate volumes compared favorably with values published for thrice weekly conventional and with short-daily hemodialysis performed with machines using much higher dialysate flow rates. Results of the present study were achieved, however, with an average of 17.5 hours of dialysis per week.     

Successful Long-Term Central Venous Access

Daily home hemodialysis (DHHD) requires simple, vascular access to minimize patients' discomfort but also to guarantee tolerance and long-term efficiency. The arteriovenous fistula is not ideal for DHHD because of the double puncture required every day; in addition, the rate of dysfunction is probably greater because of the more frequent use. Central venous catheters may be a good alternative to the arteriovenous fistula as long-term vascular access for DHHD. In this study we report our experience with the internal jugular vein two-catheter access for long-term dialysis and evaluate its possible use for DHHD. Since 1988, Tesio's twin catheters have been positioned in 908 patients with exhausted peripheral vascular bed. In all patients hemodialysis could be performed a few minutes after the surgical procedure. The survival rate of catheters, in a selected group of 46 patients, at 1, 2, and 5 years was, respectively, 92%, 87%, and 82%. The mean blood flow was 282±29 mL/min at 1 month, 286±36 mL/min at 1 year, and 274±37 mL/min at 5 years. Venous pressure in the inlet side was 102±31 mm Hg at 1 month, 126±36 mm Hg at 1 year, and 132±58 mm Hg at 5 years. Catheter clotting was treated either with thrombolytic agents or with catheter (one or both) replacement. Sepsis was treated with systemic antibiotic therapy or catheter removal. Data support the potential role of the internal jugular vein two-catheter system for DHHD.