A Trial of Extending Hemodialysis Hours and Quality of Life

Abstract

The relationship between increased hemodialysis hours and patient outcomes remains unclear. We randomized (1:1) 200 adult recipients of standard maintenance hemodialysis from in-center and home-based hemodialysis programs to extended weekly (≥24 hours) or standard (target 12-15 hours, maximum 18 hours) hemodialysis hours for 12 months. The primary outcome was change in quality of life from baseline assessed by the EuroQol 5 dimension instrument (3 level) (EQ-5D). Secondary outcomes included medication usage, clinical laboratory values, vascular access events, and change in left ventricular mass index. At 12 months, median weekly hemodialysis hours were 24.0 (interquartile range, 23.6-24.0) and 12.0 (interquartile range, 12.0-16.0) in the extended and standard groups, respectively. Change in EQ-5D score at study end did not differ between groups (mean difference, 0.04 [95% confidence interval, -0.03 to 0.11]; =0.29). Extended hours were associated with lower phosphate and potassium levels and higher hemoglobin levels. Blood pressure (BP) did not differ between groups at study end. Extended hours were associated with fewer BP-lowering agents and phosphate-binding medications, but were not associated with erythropoietin dosing. In a substudy with 95 patients, we detected no difference between groups in left ventricular mass index (mean difference, -6.0 [95% confidence interval, -14.8 to 2.7] g/m; =0.18). Five deaths occurred in the extended group and two in the standard group (=0.44); two participants in each group withdrew consent. Similar numbers of patients experienced vascular access events in the two groups. Thus, extending weekly hemodialysis hours did not alter overall EQ-5D quality of life score, but was associated with improvement in some laboratory parameters and reductions in medication burden. (Clinicaltrials.gov identifier: NCT00649298).

Independent effect of haemodialysis session frequency and duration on survival in non‐indigenous Australians on haemodialysis

“…The secondary analysis of the ACTIVE trial which is examining survival according to total weekly hours are awaited . Most of the participants who comprise the extended hours group are receiving longer session durations 3 times/week . The primary analysis in the ACTIVE trial examining the effect of increased total weekly hours on quality of life, found no significant difference between the two groups after 12 months …”

“…29 Most of the participants who comprise the extended hours group are receiving longer session durations 3 times/week. 30 The primary analysis in the ACTIVE trial examining the effect of increased total weekly hours on quality of life, found no significant difference between the two groups after 12 months. 30 Haemodialysis adequacy has conventionally been measured by urea clearance (Kt/V), which is a measure of small molecule clearance and has little to no emphasis on session duration.…”

When is more frequent hemodialysis beneficial?

“…To date, there have been three parallel‐arm randomized trials of frequent HD (Table ). A fourth trial, ACTIVE dialysis, was predominantly a trial of long three times weekly or every other day HD, and is not discussed here . In the largest trial, known as the Frequent Hemodialysis Network (FHN) Daily Trial , 245 patients from 11 centers in North America were randomized to receive conventional HD (3‐5 hours, three times weekly) or frequent short HD (1.5‐2.75 hours, six times weekly) for 12 months.…”

Changing ethnic and clinical trends and factors associated with successful home haemodialysis at Auckland District Health Board

“…In this context, improved patient‐centred management may reduce the impact of dialysis on the health system. Worldwide, the adoption of HHD is growing, and recent evidence confirms that HHD offers a cost‐effective form of RRT with overall outcomes at least equivalent to in‐centre conventional HHD, and improved quality of life for patients . HHD also provides advantages over centre‐based haemodialysis, allowing considerable patient autonomy and promoting self‐directed care .…”

“…Worldwide, the adoption of HHD is growing, and recent evidence confirms that HHD offers a costeffective form of RRT with overall outcomes at least equivalent to in-centre conventional HHD, and improved quality of life for patients. [7][8][9][10][11][12][13] HHD also provides advantages over centre-based haemodialysis, allowing considerable patient autonomy and promoting self-directed care. 14 NZ is a staunch advocate of home dialysis, with 47% of prevalent patients receiving home dialysis, approximately 40% of whom are on HHD.…”