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.     

Health-related quality of life is maintained in hemodialysis patients receiving pharmaceutical care: A 2-year randomized, controlled study

End-stage renal disease and initiation of hemodialysis (HD) adversely affect health-related quality of life (HRQOL). There are currently no data evaluating the effect of pharmaceutical care (PC) on HRQOL in HD patients. HD patients were randomized to receive PC; one-on-one, in-depth medication reviews conducted by a clinical pharmacist or Standard of Care (SOC); and brief medication reviews conducted by dialysis nurses. The renal quality of life profile (RQLP) was administered at baseline and then at 1 and 2 years after study initiation. The RQLP is a 43-item questionnaire that has 5 dimensions: Eating/Drinking, Physical Activities, Leisure Time, Psychosocial Activities, and Impact of Treatment, where increasing scores reflect worsening of HRQOL. A total of 107 patients were enrolled (SOC: n=46; PC: n=61). Besides gender, there were no differences in the demographics or the baseline total RQLP scores. The mean±SD total RQLP scores at Year 1 were significantly worse in SOC compared with PC (88±31 vs. 71±34, respectively; P=0.03). Significant worsening of Eating and Drinking (5.9±3.3 vs. 4.4±3.1, respectively; P=0.04), Physical Activities (37±13.6 vs. 30±16.3, respectively; P=0.04), and Leisure Time scores (8.3±3.4 vs. 5.9±3.6, respectively; P=0.03) was also observed in the SOC group. After 2 years, only the SOC patients had worsening of Leisure Time (7.5±3.0 vs. 5.2±3.9, respectively; P=0.04). No other parameters were different between the groups after 2 years. These data indicate that patients who have clinical care provided by pharmacists do not have worsened HRQOL after 1 year and are able to maintain HRQOL for an additional year.     

Beyond ultrapure hemodialysis: A necessary and achievable goal

Survival of chronic hemodialysis patients is worse than that of many patients with cancers or severe infections. An important cause of chronic inflammation is impurities infused into patients during dialysis. Definitions of dialysis purity have been narrow and focused on metals in dialysate water and on bacterial contaminants. There is no standard for priming fluids or toxins released directly into blood from inside the extracorporeal circuit. We propose a much broader standard of dialysis purity that also includes phthalate metabolites, bisphenols, spalled particles, and other contaminants from dialysis machines, filters, and bloodlines. Standards must include new methods for measuring bacteriological contaminants in addition to colony‐forming units and endotoxin determinations. These include the sensitive silkworm larva plasma test that detects peptidoglycan that is missed by endotoxin tests and standards for newly detected small molecular bacterial detritus. Current levels for “standard” bacteriological contaminants are woefully inadequate and should be increased. New standards for contamination with plasticizers and spallation are also necessary. Studies with ultrapure dialysis have shown almost immediate patient benefits with increased well‐being and stabilization of the cardiovascular system during and between dialyses. Intermediate effects include lower C‐reactive protein levels, better response to erythropoietin, increased appetite, and improved nutrition. Over the years, amyloidosis and carpal tunnel syndrome have become less common and cardiovascular deaths have decreased. Standards for dialysis purity must be sharpened and expanded and this becomes even more urgent with daily and long nightly hemodialysis. All contaminants received by patients, whether biological, chemical, or physical, must be considered.     

Vascular imaging for hemodialysis vascular access planning

Introduction: Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established. Methods: Retrospective cohort of patients initiating HD with CVC in 2010–2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time‐dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors. Findings: Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR = 1.45 [95% confidence interval [CI] 1.36, 1.55], P < 0.001]), any AVF or AVG (HR = 1.63 [1.58, 1.69], P > 0.001), and less likely to die (HR = 0.88 [0.83‐0.94], P < 0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02–1.16, P = 0.008). Discussion: Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.     

The path to a paradigm shift in hemodialysis

About 1 out of 4 American conventional dialysis patients die in the first year and 3 out of 5 die within 5 years with no favorable trend in sight. Largely ignored in practice is the evidence accumulated over decades that longer, more frequent dialysis can immediately slash this grim result in half or more. Pierratos has called for a paradigm shift—a disruptive change—in dialysis practice from conventional treatment to daily nocturnal dialysis, performed at home, to realize this dramatic improvement. We examine here how such a paradigm shift might be brought about and suggest that changes in 3 perspectives must occur. First, new dialysis guidelines must be recast from the old goal of minimally adequate to a new goal of best possible . Second, the body of dialysis research must be interpreted through the lens of best possible patient survival and well being, and the near-impossibility of demonstrating dialysis survival advantage through randomized clinical trials must be acknowledged. Finally, dialysis modality must be seen as, most importantly, a survival and well-being choice, not merely a Lifestyle choice; hence, it must be the nondelegatable responsibility of the physician, not dialysis center personnel, to advise and prescribe. Many old perspectives, which might stand in the way of this sorely needed paradigm shift are also examined. These old perspectives make up a fabric of excuses that has delayed—and, if not discarded, will continue to delay—progress toward a survival and well-being outlook for dialysis patients just as favorable as might be achieved through kidney transplant.     

Alternatives to standard hemodialysis

Survival of patients on hemodialysis remains poor, but the benefits of increasing urea clearance have probably been maximized within our current treatment schedules. Long dialysis sessions (8 hr) produce impressive outcomes, with mortality 53% to 55% lower than conventional schedules. Even increasing from 4 to 5 hr may improve survival. Increased frequency of dialysis (6 times weekly) produces impressive reductions in left ventricular mass and could conceivably be implemented in‐center. Preliminary data suggest a 61% reduction in mortality with increased frequency. Nightly dialysis combines longer sessions with increased frequency and has produced remarkable clinical gains in blood pressure, left ventricular mass, serum phosphate, and sleep apnea. However, the data are mainly from case series and impact on mortality remains unknown. Expansion of home hemodialysis would be necessary for this modality to grow. Convective therapies remove middle molecules more effectively, and observational data suggest hemodiafiltration has the potential to improve mortality by 35% to 36%. Hemodiafiltration has the advantage of being relatively easy to implement. The uremic milieu is complex and further investigation of the underlying pathophysiology is needed to inform future dialysis interventions. The survival data above are from observational studies, and hence benefits are likely to be exaggerated. Randomized trials of dialysis interventions are desperately needed. They remain difficult to perform, because of the complexity of both the patient population and the interventions, and because of limited available funding.     

An overlooked complication of hemodialysis: Hoarseness

In hemodialysis patients, some degree of transient hoarseness may occur at the end of the dialysis, and it may be a wearisome, recurrent, and severe state for some hemodialysis patients. However, to date, it has not been a well‐defined complication of hemodialysis. The aim of this study was to state this complication and to throw light on it. Four hundred fifty‐nine hemodialysis patients were questioned about any change in voice quality during hemodialysis. The patients who had this complaint (n = 70) were included in the study, and the group of patients who suffered hoarseness (subgroup 1: severe, subgroup 2: moderate, subgroup 3: mild) were compared with each other and with the control group, which did not suffer hoarseness (n = 51). Hoarseness was found in 15.2% of the hemodialysis patients. The duration of their hoarseness was minumum 1 to maximum 24 hours. In the control group, coronary artery disease (P = 0.056), congestive heart failure (P = 0.049), autonomic neuropathy (P = 0.001), severe intradialytic hypotensive attacks (P = 0.000), heart valve abnormalities (P = 0.000), and left ventricular diastolic dysfunction (P = 0.000) were significantly lower than in hoarseness group. Older age (P = 0.024), coronary artery disease (P = 0.014), autonomic neuropathy (P = 0.011), and intradialytic hypotensive attacks (P = 0.0001), were associated with severe and moderate hoarseness. In the comparison of % change for systolic and diastolic blood pressure between the hoarseness subgroups, diastolic blood pressure change was not different (P = 0.521), but systolic blood pressure change was statistically lower in mild group than moderate (P = 0.033) and severe subgroup (P = 0.029). Dialysis‐induced hypotension may be the main contributor of transient hoarseness. Especially elderly and cardiovascularly compromised patients, who are vulnerable to rapid changes in volume status may experience it to serious extent and this complication may be mediated by autonomic nervous control related with volume depletion.     

Quality of water in hemodialysis centers in Baghdad,Iraq

Dialysis water quality is one of the important parameters all over the world because of its direct influence on the health of kidney patients. In Iraq, there are more than 20 dialysis centers; most of them contain identical units for the production of dialysis water. In this work, the quality of water used for dialysis in six dialysis centers located within Baghdad hospitals was evaluated. Samples of product water from each of the six dialysis centers were examined for total heterotrophic bacteria, endotoxin, and chemical contaminants. Endotoxin was measured on‐site using a portable instrument. Bacteriological and chemical examinations were done in the laboratory after collecting samples from each dialysis center. The results showed a fluctuation in the produced water quality that makes the produced water unaccepted when compared with international standards. Bacterial counts for 60% of the analyzed samples were above the action level (50 colony‐forming units[CFU]/mL), while five out of the six dialysis centers showed values higher than the maximum value (100 CFU/mL). Chemical analysis showed that the dialysis water quality suffers from elevated aluminum concentration for all dialysis centers. All hemodialysis centers need thorough monitoring and preventive maintenance to ensure good water quality. In addition, it is important to revise the design of the water treatment units according to the feed and product water quality.     

The CLOCK trial,a double‐blinded randomized controlled trial: Trisodium citrate 30% and minocycline 3 mg/mL plus EDTA 30 mg/mL are effective and safe for catheter patency maintenance among CKD 5D patients on hemodialysis

Introduction: Poor blood flow rate (PF) is highly prevalent among CKD 5D patients with long‐term central venous catheters. Heparin catheter lock solutions are commonly used to maintain catheter patency, however the incidence of PF remains high. The purpose of the CLOCK Trial was to evaluate two catheter lock solutions on reduction of PF incidence. Methods: Seventy‐five CKD 5D patients on high‐efficiency hemodialysis at the Integrated Centre of Nephrology (Guarulhos, Brazil) were randomized 1:1:1 to receive a lock solution combining minocycline 3 mg/mL with the anticoagulant/chelation agent EDTA 30 mg/mL (M‐EDTA) or heparin 1000 IU/mL (H) or trisodium citrate 30% (TSC) vs. Hfor 15 weeks. A total of 68 patients completed the trial in which both investigators and patients were blinded to treatment allocation. The primary end‐point was the occurrence of hydraulic resistance and secondary safety end‐point was adverse drug reactions related to the lock solutions. Findings: At the beginning of the trial, 7 patients were excluded from this trial due to their poor catheter care. The incidence of hydraulic resistance was significantly higher among patients on H (18/23) compared to TSC (4/22) and M‐EDTA (2/23) lock solutions, (P < 0.001). Discussion: The CLOCK Trial suggests TSC and M‐EDTA may preserve catheter patency better than H. TSC may be a better option due the lack of association with long‐term antimicrobial resistance.     

Safety analysis of intermittent hemodialysis in patients with continuous flow left ventricular assist devices

Dialysis centers adopt a cautious approach when it comes to performing intermittent hemodialysis (HD) on patients with continuous flow (CF) left ventricular assist devices (LVADs) because of the potential for volume flux‐related complications and absence of pulsatile blood pressure for monitoring. Many patients have to remain hospitalized because of the inability of the dialysis centers to accept them for outpatient dialysis. In this study, the effect of HD was observed in such patients. Between June 2009 and October 2012, 139 patients received LVADs, of which 10 patients (7%) required intermittent HD postoperatively. The mean age of the patients was 53 ± 14 years and 90% were men. A total of 281 dialysis sessions were administered amounting to 1025 hours of dialysis. The mean systolic blood pressure monitored with Doppler device was 97 ± 18 mmHg. Dialysis durations averaged 218 ± 18 minutes. Mean blood flow rate was 334 ± 38 cc/min, and 2.6 ± 1.1 L was ultrafiltrated during each session. Only 15 (5.3%) sessions were interrupted or terminated in six patients. The reasons for termination were symptomatic hypotension—6 (2.1%), asymptomatic hypotension—3 (1%), ventricular tachycardia—1 (0.36%), dialysis machine malfunction—2 (0.7%), low phosphorus—2 (0.7%), and abdominal cramps—1 (0.36%). Volume expansion was necessary on three occasions. Low‐flow device alarms were registered during two (0.71%) sessions. The results showed no serious adverse effects or deaths.     

Quality of hemodialysis water in a resource‐poor country: The Nigerian example

Hemodialysis (HD) patients are exposed to large volumes of water, separated from patients' blood by semipermeable membrane of dialyzers. Chemical contaminants in poorly treated water impact negatively on quality of life of these patients. This survey was carried out to assess the HD water quality in Lagos, Nigeria. Ten milliliters of feed and treated water from all six HD centers in Lagos were tested for aluminum, copper, zinc, magnesium, calcium using atomic absorption spectrometry; sodium and potassium were tested using flame photometry, fluoride with molecular photoluminescence method; sulfate using turbidimetry, nitrates measured by cadmium column reduction method, chloramines and free chlorine were measured using N, N‐diethyl‐1‐P‐phenylenediamine colorimetric method. Information on sources of feed water, frequency of testing of HD water, methods of water treatment, type of water purification system and maintenance was also obtained. All centers used borehole as main source of water supply. None of the centers met Association for the Advancement of Medical Instrumentation (AAMI) guidelines for most chemical contaminants. Only chlorine (0.48 ± 0.07 mg/L) and potassium (3.9 ± 0.95 mg/L) levels met AAMI standards after treatment. Mean levels of chemical contaminants in treated water were as follows: aluminum 0.04 ± 0.01 mg/L, zinc 0.27 ± 0.08 mg/L, chloramines 0.16 ± 0.03 mg/L, fluoride 1.83 ± 0.40 mg/L, sulfate 117 ± 86.1 mg/L which were mildly elevated; calcium 126.00 ± 22.7 mg/L, sodium 179 ± 25.6 mg/L, and nitrate 70.5 ± 50.8 mg/L, which were markedly elevated; and magnesium 8.3 ± 3.38 mg/L, which was moderately elevated above AAMI recommended levels. HD water quality is poor in our environment. Concerted efforts are required to ensure good quality water for HD.     

Automatic feedback control of relative blood volume changes during hemodialysis improves blood pressure stability during and after dialysis

Automatic feedback systems have been designed to control relative blood volume changes during hemodialysis (HD) as hypovolemia plays a major role in the development of dialysis hypotension. Of these systems, one is based on the concept of blood volume tracking (BVT). BVT has been shown to improve intra-HD hemodynamic stability. We first questioned whether BVT also improves post-HD blood pressure stability in hypotension-prone patients and second, whether BVT is effective in reducing the post-HD weight as many hypotension-prone patients are overhydrated because of an inability to reach dry weight. After a 3-week period on standard HD, 12 hypotension-prone patients were treated with two consecutive BVT treatment protocols. During the first BVT period of 3 weeks, the post-HD target weight was kept identical compared with the standard HD period (BVT-constant weight; BVT-cw). During the second BVT period of 6 weeks, we gradually tried to lower the post-HD target weight (BVT-reduced weight; BVT-rw). In the last week of each period, we studied intra-HD and 24 hr post-HD blood pressure behavior by ambulatory blood pressure measurement (ABPM). Pre- and post-HD weight did not differ between standard HD and either BVT-cw or BVT-rw. Heart size on a standing pre-dialysis chest X-ray did not change significantly throughout the study. There were less episodes of dialysis hypotension during BVT compared with standard HD (both BVT periods: p<0.01). ABPM data were complete in 10 patients. During the first 16 hr post-HD, systolic blood pressure was significantly higher with BVT in comparison with standard HD (both BVT periods: p<0.05). The use of BVT in hypotension-prone patients is associated with higher systolic blood pressures for as long as 16 hr post-HD. BVT was not effective in reducing the post-HD target weight in this patient group.     

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.