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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