Intensive Hemodialysis and Potential Risks With Increasing Treatment

Abstract

Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.

Intensive Hemodialysis and Treatment Complications and Tolerability

“…Meaningful reductions in the incidence of IDH and length of recovery time may be achieved with intensive HD, but at the expense of 2 to 3 additional HD sessions per week, increased risk for vascular access complications, and in the home setting, increased burden on care partners. [30][31][32] Moreover, lower risk for treatment complications with intensive HD may fail to translate to lower risks for mortality and morbidity. With extended follow-up of FHN Trial participants, short daily HD reduced the risk for death by 46%, relative to 3 sessions per week, but nocturnal HD increased risk by 288%, despite much lower ultrafiltration rates with nocturnal HD versus short daily HD.…”

Intensive Hemodialysis: Time to Give the Therapy Greater Consideration

“…The final review addresses potential risks and limitations of intensive HD in the settings of both dialysis facility and home. 31 Kraus et al 31 acknowledge that although intensive HD addresses many of the persistent complications of conventional HD, there are specific concerns regarding vascular access complications; infection; potential loss of residual kidney function, with aggressive ultrafiltration; solute balance, particularly with nocturnal therapy; patient and care partner burden; and mortality. Many of the complications encountered with intensive HD are rooted in the breadth of experience of the care team that trains, monitors, and supports patients, especially in the home setting.…”

The effect of extended‐hours hemodialysis on outcomes: A systematic review and meta‐analysis

“…There is a paucity of data regarding the impact of extended‐hours hemodialysis on residual kidney function. Given the positive association between preserved residual kidney function and survival, the report by Daugirdas et al which demonstrated an increased proportion of patients in the nocturnal arm with zero or reduced renal function compared to baseline raises concerns . Data are also emerging that suggest incremental amounts of prescribed hemodialysis in patients with significant residual kidney function may slow its eventual decline .…”