Decreasing Non-COVID-19 Hospitalizations in Dialysis Patients
Opinion article
Physician and Physician Extender Clinical Practice Considerations
Caring for Dialysis Patients During the COVID-19 Epidemic
On March 13, 2020, the U.S. administration instituted a national emergency, as nearly 200,000 COVID-19 cases presented worldwide.1 This is a novel disease and a rapidly evolving situation in the U.S., with the number of newly confirmed cases increasing by 20k-30k per day.2
The COVID-19 pandemic has the potential to strain many hospital systems and supply chains, putting hospital beds, tests, masks, gloves, and antibacterial and pharmaceutical supplies at risk.
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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 per session.
The implication of this schedule is that we have 3 interdialytic gaps per week, including one gap of approximately 68 hours, during which fluid accumulates in the body, and we have all of 11 hours during which the hemodialysis machine removes that fluid.
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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”) submissions in 2017 were treated with PD.2 In addressing the goal of dialyzing more patients at home, this is a genuine accomplishment.
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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 number of people undergoing chronic dialysis.
Dialysis Patient Population Growth
Today, that number exceeds 510,000. Nevertheless, the annualized rate of growth in the dialysis patient population has recently slipped below 2%.
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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 investigators in the Frequent Hemodialysis Network (FHN) trial, posed and answered this timely question in a thoughtful narrative review that appears in the July/August issue of Seminars in Dialysis.
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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 of Kidney International, Prabir Roy-Chaudhury and colleagues published one such study. These investigators reported data from a prospective, multicenter study, the Monitoring in Dialysis (MiD) Study, which was conducted in both the United States and India and aimed to estimate the proportion of thrice-weekly hemodialysis patients who experienced clinically significant arrhythmias during 6 months of follow-up.
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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 II receptor blockers (ARBs). In most clinical practice guidelines, ACE inhibitors are recommended as first-line therapy, while ARBs are recommended as a second option for patients who cannot tolerate an ACE inhibitor, typically because of a dry, persistent cough and atypically because of angioedema.
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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, these targets are applicable to both in-center hemodialysis and home hemodialysis alike.
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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 pressure is linearly associated with risk of cardiovascular events.1,2
As clinicians, how should we respond to this challenge?
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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.
In the United States, Medicare requires medical justification for reimbursement of additional hemodialysis sessions (i.e., treatment beyond 3 sessions per week). Clinical practice guidelines not only from the United States, but also from Japan, the United Kingdom, Europe, and Canada together encourage physicians to consider applications of longer and more frequent hemodialysis sessions in patients with cardiovascular complications, including left ventricular hypertrophy and uncontrolled hypertension; hemodynamic instability during dialysis, possibly due to excessive ultrafiltration intensity; hyperphosphatemia; and malnutrition.
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