Choices in hemodialysis therapies: variants, personalized therapy and application of evidence-based medicine

Abstract

The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of ‘flux’ of membranes as well toxicity of compounds that need to be targeted for removal remain unresolved issues, the relative role, efficiency and utilization of solute removal principles to optimize HD treatment are better delineated. Through the combination and intensity of diffusive and convective removal forces, levels of concentrations of a broad spectrum of uremic toxins can be lowered significantly and successfully. Extended clinical experience as well as data from several clinical trials attest to the benefits of convection-based HD treatment modalities. However, the mode of delivery of HD can further enhance the effectiveness of therapies. Other than treatment time, frequency and location that offer clinical benefits and increase patient well-being, treatment- and patient-specific criteria may be tailored for the therapy delivered: electrolytic composition, dialysate buffer and concentration and choice of anticoagulating agent are crucial for dialysis tolerance and efficacy. Evidence-based medicine (EBM) relies on three tenets, i.e. clinical expertise (i.e. doctor), patient-centered values (i.e. patient) and relevant scientific evidence (i.e. science), that have deviated from their initial aim and summarized to scientific evidence, leading to tyranny of randomized controlled trials. One must recognize that practice patterns as shown by Dialysis Outcomes and Practice Patterns Study and personalization of HD care are the main driving force for improving outcomes. Based on a combination of the three pillars of EBM, and particularly on bedside patient–clinician interaction, we summarize what we have learned over the last 6 decades in terms of best practices to improve outcomes in HD patients. Management of initiation of dialysis, vascular access, preservation of kidney function, selection of biocompatible dialysers and use of dialysis fluids of high microbiological purity to restrict inflammation are just some of the approaches where clinical experience is vital in the absence of definitive scientific evidence. Further, HD adequacy needs to be considered as a broad and multitarget approach covering not just the dose of dialysis provided, but meeting individual patient needs (e.g. fluid volume, acid–base, blood pressure, bone disease metabolism control) through regular assessment—and adjustment—of a series of indicators of treatment efficiency. Finally, in whichever way new technologies (i.e. artificial intelligence, connected health) are embraced in the future to improve the delivery of dialysis, the human dimension of the patient–doctor interaction is irreplaceable. Kidney medicine should remain ‘an art’ and will never be just ‘a science’.

Time-averaged concentration estimation of uraemic toxins with different removal kinetics: a novel approach based on intradialytic spent dialysate measurements

“…Although the TAC concept offers additional information on HD adequacy, HD adequacy should be multitargeted and cover all patient needs and clinical goals that improve outcomes [ 14 , 43 , 44 ]. Kt/V has been criticized for ignoring the question of how much uraemic toxin is left in the patient [ 4 ].…”

Personalized Management of Sodium and Volume Imbalance in Hemodialysis to Mitigate High Costs of Hospitalization

“…However, achieving the ultimate target of normovolemia has been difficult mainly because of the intermittent and short HD treatment regimens combined with inappropriate adherence to strict salt restriction diet [40]. This is why a more personalized dialysis prescription and treatment schedule (e.g., intensified dialysis, longer or more frequent) [78] is required to adequately address sodium-water imbalance.…”

Fluid Overload and Tissue Sodium Accumulation as Main Drivers of Protein Energy Malnutrition in Dialysis Patients

“…Fluid and sodium management represents a key component in dialysis patients working both ways—on one side to prevent fluid overload when secondary catabolism occurs and on the other side to prevent protein–energy wasting associated with chronic fluid overload [ 51 ]. Several recent reviews have been dedicated to this topic, to which we refer interested readers for more detailed information [ 54 , 92 , 93 ]. In this paragraph, we summarized the main points to address this problem in two sections: Firstly, how to monitor adequately fluid status of dialysis patients; secondly, how to restore fluid and sodium homeostasis.…”