Published Clinical Evidence Supporting More Frequent Home Hemodialysis

“Thrice-weekly treatment may be inadequate for addressing the critical problems of persistent fluid overload, hypertension, left ventricular hypertrophy, and recurrent vascular access infections and complications.”

U.S. Renal Data System, USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Volume 2, Chapter 5: Mortality, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2011.

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Recent studies of interest:

Clinical Evidence By Category:

Mortality Risk and Survival

Mortality rates for conventional in-center hemodialysis in the U.S. remain at approximately 20% annually, with a 3 year survival rate of 50%.11

Compared to conventional thrice-weekly dialysis patients, those performing more frequent home hemodialysis treatments may have an increased chance of survival.

Left Ventricular Mass

"Regression of left ventricular hypertrophy (LVH) in the setting of a well-planned intervention study has been associated with longer survival in hemodialysis patients."2

Patients performing more frequent hemodialysis may experience significant reductions in left ventricular mass when compared to patients performing thrice-weekly in-center hemodialysis.

Time to Recovery and Post-Dialysis Fatigue

Post-dialysis fatigue, often described as a "washed-out" feeling, may limit dialysis patients for many hours post treatment, impacting quality of life.3

More frequent hemodialysis may improve time to recovery and post-dialysis fatigue.

Blood Pressure Control and Use of Antihypertensives

Hypertension is very common and often poorly controlled in patients undergoing long-term hemodialysis therapy, contributing to increased cardiovascular morbidity in this population.4

More frequent hemodialysis is associated with improved blood pressure control and a reduction in anti-hypertensive medications.

Phosphorus Control

"Hyperphosphatemia is an almost universal finding in patients with end-stage renal disease and is associated with increased all-cause mortality, cardiovascular mortality, and vascular calcification."5

More frequent hemodialysis has been associated with improved control of hyperphosphotemia.

Depressive Symptoms

Clinical depression is an important concern for patients with kidney failure and can have a negative impact on quality of life and survival. In this patient population, the prevalence of depression is reported to be as high as 20%-30%.6

More frequent hemodialysis may reduce depressive symptoms.

Mental and Physical Health

As reported in the Dialysis Outcomes and Practice Patterns Study (DOPPS), lower health related quality of life scores in dialysis patients have been strongly associated with significantly higher risk of death and hospitalizations.7

More frequent hemodialysis may improve mental and physical health.

Sleep Quality and Restless Legs Syndrome

Poor sleep quality has been reported in half (49%) of dialysis patients and is independently associated with lower QOL scores, higher use of narcotics and antidepressants, and increased relative risk of mortality. Symptoms of RLS have been reported in up to 30% of ESRD patients and have been associated with a lower QOL and increased risk for death.8,9

More frequent hemodialysis may improve sleep quality, reduce sleep disturbances, and reduce the incidence and severity of Restless Legs Syndrome.

Nutrition Status

Malnutrition is a common problem in hemodialysis patients and one of the most important factors influencing morbidity and mortality.10

More frequent hemodialysis has been associated with improvements in nutritional parameters.

A note on vascular access: The Frequent Hemodialysis Network's Daily Trial found that frequent hemodialysis, as compared with conventional hemodialysis, prompted more frequent interventions related to vascular access. Specifically, the frequent hemodialysis group was more likely to undergo interventions both in the analysis of time to first intervention, and multiple interventions.1

Despite the health and quality of life benefits that frequent home hemodialysis may provide to those with chronic kidney disease, this form of therapy is not for everyone. The reported benefits of frequent hemodialysis may not be experienced by all patients. The risks associated with hemodialysis treatments in any environment include, but are not limited to, high blood pressure, fluid overload, low blood pressure, heart-related issues, and vascular access complications. The medical devices used in hemodialysis therapies may add additional risks including air entering the bloodstream, and blood loss due to clotting or accidental disconnection of the blood tubing set.

Certain risks are unique to the home. Treatments at home are done without the presence of medical personnel and on-site technical support. Patients and their partners must be trained on what to do and how to get medical or technical help if needed.

References

  1. The FHN Trial Group. In-center hemodialysis six times per week versus three time per week. New England Journal of Medicine 2010; 363:2287-2300.
  2. Zoccali C., et al. Left ventricular mass monitoring in the follow-up of dialysis patients: Prognostic value of left ventricular hypertrophy progression. Kidney International (2004) 65, 1492–1498.
  3. Jaber B, et al. Effect of Daily Hemodialysis on Depressive Symptoms and Postdialysis Recovery Time: Interim Report From The FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcomes Measurements) Study. Am J Kidney Dis 2010;56:531-539.
  4. Rahman M, et al. Patterns of Antihypertensive Medication Use in Hemodialysis Patients. American Journal of Healthy-System Pharmacy. 2004;61(14).
  5. Kooienga L. PHOSPHORUS METABOLISM AND MANAGEMENT IN CHRONIC KIDNEY DISEASE: Phosphorus Balance with Daily Dialysis. Seminars in Dialysis 2007;20:342-345.
  6. Jaber B, et al. Effect of Daily Hemodialysis on Depressive Symptoms and Postdialysis Recovery Time: Interim Report From The FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcomes Measurements) Study. Am J Kidney Dis 2010;56:531-539.
  7. Mapes D, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney International 2003;64;339–349
  8. Elder SJ, et al. Sleep quality predicts quality of life and mortality risk in haemodialysis patients: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2008;23;998–1004.
  9. Unruh M, et al. Restless legs symptoms among incident dialysis patients: Association with lower quality of life and shorter survival. Am J Kidney Disease 2004;43:900-909
  10. Spanner E, et al. The impact of quotidian hemodialysis on nutrition. Am J Kidney Dis 2003; 42 Supp 1: 30-35.
  11. U.S. Renal Data System, USRDS 2011 Annual Data Report: Atlas of End-Stage Renal Disease in the United States
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