Mineral and bone disease is a common complication of kidney failure.1 There is a significant gap between phosphorus absorption and clearance in conventional hemodialysis.2,3 In 2015, over 36% of hemodialysis patients had serum phosphorus persistently above the target range.4 Hyperphosphatemia is associated with higher risk of cardiovascular mortality and morbidity, but treating hyperphosphatemia with phosphate binders is burdensome to both patients and payers.1,5,6,7
Trials show intensive hemodialysis reduced serum phosphorus and the need for phosphate binders
Multiple randomized clinical trials show that intensive hemodialysis reduced serum phosphorus:
- In the Frequent Hemodialysis Network trials, short daily and nocturnal schedules, each for six sessions per week, reduced serum phosphorus by 0.6 and 1.6 mg/dL, respectively, relative to three sessions per week.8
- A similar effect of nocturnal hemodialysis was observed in an earlier Canadian trial.9
- In the Frequent Hemodialysis Network daily trial, intensive hemodialysis significantly lowered estimated phosphate binder dose (EPBD) per day.8
- In the Canadian nocturnal trial, intensive hemodialysis led to phosphate binder discontinuation in 73% of patients.9
Intensive hemodialysis effectively lowers serum phosphorus and markedly reduces the use of phosphate binders. Frequent nocturnal hemodialysis may positively address hyperphosphatemia to the extent that supplementation with dialysate phosphorus may be necessary to avoid development of hypophosphatemia. The effect of intensive hemodialysis on phosphorus concentration suggests that the progression of vascular calcification may be slowed, thereby leading to cardiovascular risk reduction.
Reduction in the use of phosphate binders not only decreases pill burden, but also contains a rapidly growing source of health care costs in the dialysis patient population, an especially important consideration in the setting of capitated reimbursement.