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A question of balance: Benefits vs. risks of intensive hemodialysis

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Although intensive hemodialysis may address important clinical problems, increasing treatment may introduce risks pertaining to six domains: vascular access complications, infection, mortality, loss of residual renal function, solute balance, and patient and care partner burden.

Trials have shown increased access complications and infection

  • In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased incidence of access complications, most commonly due to infection, although incidence of access loss was not statistically elevated. 1
  • Observational studies regarding vascular access complications are mixed.2,3
  • Excess risk may be catalyzed by poor infection control practices in the home setting, where intensive hemodialysis is typically delivered, but with an assumption of fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases risk of infectious complications.4,5

Data regarding mortality are equivocal

  • With extended follow-up of subjects in the FHN trials, short daily hemodialysis was associated with lower risk of death, relative to conventional hemodialysis, while nocturnal hemodialysis was associated with higher risk. However, the FHN trials were never powered to assess mortality and suffer from significant limitations, including substantial crossover in treatment schedules after 12 months of follow-up.5,6,7
  • In many – but not all – observational studies, short daily hemodialysis has been associated with lower risk than both in-center hemodialysis and peritoneal dialysis; however, observational studies are subject to unmeasured confounding.8,9

Increased treatment may increase loss of residual renal function burden on caregivers and may deplete solutes

  • Intensive hemodialysis has been reported to accelerate the loss of residual renal function in incident dialysis patients with substantial urine output, relative to conventional hemodialysis, and may deplete solutes (eg., phosphorus), to the extent that supplementation is necessary.10,11,12
  • Intensive hemodialysis may increase burden on caregivers, possibly leading to technique failure.13

Conclusion

Ultimately, intensive hemodialysis is not a panacea for kidney failure. In spite of the benefits of intensive hemodialysis on cardiovascular function, health-related quality of life, and treatment tolerability, intensive hemodialysis may introduce specific risks pertaining to vascular access complications, infections, loss of residual renal function and increased burden on caregivers. As much as enthusiasm for the clinical effects of intensive hemodialysis may be warranted, patients and clinicians must consider the potential disadvantages of dialyzing more frequently and consider both the potential benefits and risks of treatment and prepare for possible adverse effects.

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All forms of hemodialysis, including treatments performed in-center and at home, involve some risks. In addition, there are certain risks unique to treatment in the home environment. Patients differ and not everyone will experience the reported benefits of more frequent hemodialysis.

Certain risks associated with hemodialysis treatment are increased when performing solo home hemodialysis because no one is present to help the patient respond to health emergencies.

Certain risks associated with hemodialysis treatment are increased when performing nocturnal therapy due to the length of treatment time and because therapy is performed while the patient and care partner are sleeping.

References

  1. Suri RS, Larive B, Sherer S, et al. Risk of vascular access complications with frequent hemodialysis. JASN. 2013;24(3):498-505. doi:10.1681/ASN.2012060595
  2. Lindsay RM, Leitch R, Heidenheim AP, Kortas C, London Daily/Nocturnal Hemodialysis Study. The London Daily/Nocturnal Hemodialysis Study–study design, morbidity, and mortality results. Am J Kidney Dis. 2003;42(1 Suppl):5-12.
  3. Achinger SG, Ikizler TA, Bian A, Shintani A, Ayus JC. Long-term effects of daily hemodialysis on vascular access outcomes: a prospective controlled study. Hemodial Int. 2013;17(2):208-215. doi:10.1111/j.1542-4758.2012.00756.x.
  4. Spry, L.A., Burkart, J.M., Holcroft, C., Mortier, L., Glickman, J.D. Survey of home hemodialysis patients and nursing staff regarding vascular access use and care. Hemodial Int. 2015;19:225–234.
  5. Kraus, M.A., Kansal, S., Copland, M. et al, Intensive hemodialysis and potential risks with increasing treatment. Am J Kidney Dis. 2016;68:S51–S58.
  6. Chertow GM, Levin NW, Beck GJ, et al. Long-Term Effects of Frequent In-Center Hemodialysis. JASN. October 2015.doi:10.1681/ASN.2015040426.
  7. Rocco MV, Daugirdas JT, Greene T, et al. Long-term Effects of Frequent Nocturnal Hemodialysis on Mortality: The Frequent Hemodialysis Network (FHN) Nocturnal Trial. Am J Kidney Dis. 2015;66(3):459-468. doi:10.1053/j.ajkd.2015.02.331.
  8. Weinhandl, E.D., Liu, J., Gilbertson, D.T., Arneson, T.J., Collins, A.J. Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. J Am Soc Nephrol. 2012;23:895–904.
  9. Weinhandl, E.D., Gilbertson, D.T., Collins, A.J. Mortality, hospitalization, and technique failure in daily home hemodialysis and matched peritoneal dialysis patients: a matched cohort study. Am J Kidney Dis. 2016;67:98–110.
  10. Daugirdas JT, Greene T, Rocco MV, et al. Effect of frequent hemodialysis on residual kidney function. Kidney Int. 2013;83(5):949-958. doi:10.1038/ki.2012.457.
  11. Daugirdas JT, Chertow GM, Larive B, et al. Effects of frequent hemodialysis on measures of CKD mineral and bone disorder. JASN. 2012;23(4):727-738. doi:10.1681/ASN.2011070688.
  12. Hedayati SS. Dialysis-related carnitine disorder. Semin Dial. 2006;19(4):323-328. doi:10.1111/j.1525-139X.2006.00180.x.
  13. Suri RS, Larive B, Hall Y, et al. Effects of frequent hemodialysis on perceived caregiver burden in the Frequent Hemodialysis Network trials. CJASN. 2014;9(5):936-942. doi:10.2215/CJN.07170713.