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Recent Findings

Better Management of Volume with Intensive Hemodialysis

In the March issue of Nephrology News & Issues, I described the challenge of managing volume during and between hemodialysis sessions. The root of the challenge is the intermittent nature of hemodialysis. In the dominant schedule, intermittency is marked by 3 hemodialysis sessions per week, either on Monday-Wednesday-Friday or Tuesday-Thursday-Saturday, for 210 to 230 minutes… Read More

Transitioning from Peritoneal Dialysis to Hemodialysis

During the past decade, the use of peritoneal dialysis (PD) in the United States has grown substantially.1 In 2009, 7.5% of dialysis patients were treated with PD; by 2016, the statistic had increased to 10.0%.1 And according to the United States Renal Data System (USRDS), 10.5% of dialysis patients with new Medical Evidence Report (“2728”)… Read More

Recasting Kidney Failure as Cardiovascular Disease

Total Medicare expenditures on the health care of patients with permanent kidney failure have steadily risen to more than $35 billion per year, although per capita expenditures on the care of dialysis patients have been relatively stable in recent years.1 This conflict in trends can be readily explained by the seemingly unstoppable increase in the… Read More

When is More Frequent Hemodialysis Beneficial?

In 2017, Medicare Administrative Contractors (MACs) began to promulgate draft local coverage determinations that include restrictive language regarding Medicare reimbursement for additional hemodialysis sessions. An important element of the draft determinations is medical justification, or the clinical conditions that constitute evidence-based rationale for the prescription of more frequent hemodialysis. Suri and Kliger, who were both… Read More

Cardiac Arrhythmia: An Ominous Side Effect of Thrice-weekly Hemodialysis?

Many studies represent incremental gains in our understanding of human pathophysiology. Some studies, especially large randomized clinical trials, can singlehandedly change the standard of care. Other studies, at the most unexpected times, flash a signal that raises the question of whether the widely accepted standard of care is simply inadequate. In the April 2018 issue… Read More

ACE Inhibitors or ARBs: Which to Prescribe?

Many dialysis patients, including patients on frequent home hemodialysis, have been diagnosed with heart failure. In one large study, 31% of patients who initiated home hemodialysis already had heart failure.1 One of the cornerstones of pharmacologic therapy for heart failure is renin-angiotensin system blockade, which may be achieved with either angiotensin-converting enzyme (ACE) inhibitors or angiotensin… Read More

Standardized Kt/V on Home Hemodialysis: Does It Matter?

Hemodialysis adequacy has historically been assessed through the lens of Kt/V. Standardized Kt/V is a metric that specifically permits comparisons of urea clearance among heterogeneous hemodialysis schedules. Current clinical practice guidelines from the Kidney Disease Outcomes Quality Initiative (KDOQI) suggest a target standardized Kt/V of 2.3, and a minimal standardized Kt/V of 2.1.1 In principle,… Read More

Hypertension in Dialysis Patients

The link between hypertension, left ventricular hypertrophy, heart failure, and sudden death is clear. In the dialysis population, persistent hypertension is observed in the majority of patients, making it a fundamental and unmet challenge. Accumulating evidence shows that ambulatory blood pressure is a better predictor of survival than in-unit blood pressure—and, importantly, that ambulatory blood… Read More

International Guidelines for Increased Hemodialysis Time and Frequency

During the past 10 years, there has been a proliferation of research about intensive hemodialysis, including both longer and more frequent hemodialysis sessions. The accumulation of data from studies has led to the development of clinical practice guidelines about hemodialysis time and frequency, with a focus on identifying indications for increasing time and frequency.  … Read More

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