Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/Vurea, a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Thus, we were unable to demonstrate a definitive benefit of more frequent nocturnal hemodialysis for either coprimary outcome.

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Coronavirus disease 2019 (COVID-19), a pandemic sweeping the world's population, is particularly threatening to patients on dialysis. This concise publication brings the evidence-based guidance of the Centers for Disease Control and Prevention (CDC) and the practical judgment of dialysis clinicians, brought together by the American Society of Nephrology (ASN), to inform best practice for in-center hemodialysis. COVID-19 is a novel coronavirus disease caused by the severe acute respiratory syndrome coronavirus 2. Patients usually present with fever (44%-98%), cough (68%-76%), myalgia (18%), and fatigue (18%) (1,2). The infectivity of this virus is high enough to assure pandemic spread if no mitigating efforts are made to stop it. Based on data from the Diamond Princess cruise ship COVID-19 outbreak, the maximum-likelihood value of the reproductive number (R 0) was 2.8 (3). Mortality has been estimated at 1.4%-3.6% (1,2), but could be higher (4) or lower as case finding increases. Children weather the infections well, with few complications (5). Older age and comorbid hypertension, diabetes, neutrophilia, and organ and coagulation dysfunction are risk factors for adult respiratory distress syndrome and death (6). Because the approximately 0.5 million United States residents receiving maintenance dialysis treatment are primarily in this high-risk group, dialysis facilities and the professionals caring for these patients must be prepared to safely manage them and protect noninfected patients and staff from acquiring this infection. A recent report nicely describes what is currently known about COVID-19 infection and kidneys (7). During the Ebola epidemic of 2014, patients with suspected disease were generally referred to hospitals for diagnosis and treatment. Dialysis for patients with Ebola in the United States was provided exclusively in the inpatient setting, with the structural and procedural safeguards to prevent infection transmission. This was practical because the number of patients who were infected was small. Patients were referred to a few centers with the expertise to care for them. The challenge of COVID-19 is very different: as the disease spreads in a community, many patients on dialysis in the same geographic area are likely to become infected and require continued dialysis treatments. Thriceweekly dialysis poses the risk of infection spread among patients and staff. Early in this pandemic, patients on dialysis who are symptomatic may be referred to hospital for diagnosis and management.

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Observational studies suggest improvements with frequent hemodialysis (HD), but its true efficacy and safety remain uncertain. The Frequent Hemodialysis Network Trials Group is conducting two multicenter randomized trials of 250 subjects each, comparing conventional three times weekly HD with (1) in-center daily HD and (2) home nocturnal HD. Daily HD will be delivered for 1.5-2.75 h, 6 days/week, with target eK(t)/V(n) > or = 0.9/session, whereas nocturnal HD will be delivered for > or = 6 h, 6 nights/week, with target stdK(t)/V of > or = 4.0/week. Subjects will be followed for 1 year. The composite of mortality with the 12-month change in (i) left ventricular mass index (LVMI) by magnetic resonance imaging, and (ii) SF-36 RAND Physical Health Composite (PHC) are specified as co-primary outcomes. The seven main secondary outcomes are between group comparisons of: change in LVMI, change in PHC, change in Beck Depression Inventory score, change in Trail Making Test B score, change in pre-HD serum albumin, change in pre-HD serum phosphorus, and rates of non-access hospitalization or death. Changes in blood pressure and erythropoiesis will also be assessed. Safety outcomes will focus on vascular access complications and burden of treatment. Data will be obtained on the cost of delivering frequent HD compared to conventional HD. Efforts will be made to reduce bias, including blinding assessment of subjective outcomes. Because no large-scale randomized trials of frequent HD have been previously conducted, the first year has been designated a Vanguard Phase, during which feasibility of randomization, ability to deliver the interventions, and adherence will be evaluated.

Context In light of conflicting evidence of differential effects of dialysis modality on survival, patient experience becomes a more important consideration in choosing between hemodialysis and peritoneal dialysis. Objective To compare patient satisfaction with hemodialysis and peritoneal dialysis in a cohort of patients who have recently begun dialysis. Design and Setting Cross-sectional survey at enrollment in a prospective inception cohort study of patients who recently started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998. Patients Of 736 enrolled incident dialysis patients, 656 (89%) returned a satisfaction questionnaire after an average of 7 weeks of dialysis. Main Outcome Measure Data collected from a patient-administered questionnaire including 3 overall ratings and 20 items rating specific aspects of dialysis care. Results Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85% vs 56%, respectively; relative probability, 1.46 [95% confidence interval, 1.31-1.57]) and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69% excellent] vs hemodialysis [30% excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist, response to pain, amount of fluid removed, and staff availability in an emergency. Adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis did not reduce the differences between peritoneal dialysis and hemodialysis patients. Conclusions After several weeks of initiating dialysis, patients receiving peritoneal dialysis rated their care higher than those receiving hemodialysis. These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.

The risk for death in patients with ESRD undergoing dialysis depends on dialysis type. Further studies are needed to evaluate a possible survival benefit of a timely change from peritoneal dialysis to hemodialysis.

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