Nocturnal home hemodialysis with low‐flow dialysate: Retrospective analysis of the first European patients

Abstract

Introduction: Despite mounting evidence that increased frequency and duration of hemodialysis (HD) improves outcomes, less than 1% of HD patients worldwide receive nocturnal hemodialysis (NHD). Many perceived barriers exist to providing NHD and increasing its provision.Methods: A retrospective analysis of nocturnal therapy using a low-flow dialysate system in 4 European centers for a minimum of 12 months, with data collected on patient demographics, training times, safety features, medications, and biochemical parameters at baseline and at 6 and 12 months.Findings: Data were collected on 21 patients, with 12-month analysis available for 20 patients. Mean dialysis duration was 28 hours per week, with most dialysis on an alternate night regimen using 50-60 L of dialysate per session. All vascular access types were represented, and low molecular weight heparin was used as a bolus. All biochemical parameters met European standards, with a trend for improvement in standardized Kt/V, phosphate, hemoglobin, and albumin. There was a significant reduction in phosphate binder usage and a reduction in blood pressure medication. Training time was 9.6 sessions for independence at home, with 2 additional sessions to transition to NHD. Additional safety features included an alarmed drip tray under the cycler and moisture sensors under the venous needle (all patients used dual-cannulation technique). No patient safety events were reported.Discussion: These data support the use of a low-flow dialysate system for provision of NHD at home. Biochemical parameters were good, medication burden was reduced at 12 months, and all patients received more than double the duration of HD provided in standard in-center units. While patient numbers were small, low-flow dialysis in this cohort was both effective and safe. Use of this alternative HD system could reduce some of the barriers to NHD, increasing the uptake of therapy in Europe, and improving long-term patient outcomes.

Long-Term In-Center Nocturnal Hemodialysis Improves Renal Anemia and Malnutrition and Life Quality of Older Patients with Chronic Renal Failure

“…In a retrospective analysis of NHHD in four European centers for a minimum of 12 months, it was found that NHHD was both effective and safe at improving long-term patient outcomes. 14 In the study of Wong et al, INHD was associated with increased hemoglobin levels and lower serum phosphate levels. These results are the same as those represented in our study, which found a significant increase in the serum hemoglobin concentration ( p < 0.05) in the older patients with ESRD after INHD treatment.…”

Optimizing serum total carbon dioxide concentration during short and nocturnal frequent hemodialysis using lactate as dialysate buffer base

“…The HD treatment prescriptions studied were chosen to be representative of those used in current clinical practice (internal data from NxStage Medical) and in recent literature. 3 The current study used the H + mobilization model as described previously, 4,5 together with clinical data from patients who transferred from ICHD to daily home HD during the FREEDOM study to calculate acid generation rates for the study patient population. Assuming those generation rates were independent of the FHD treatment prescription, the H + mobilization model was then used to predict the effect of dialysate lactate concentration on predialysis serum tCO 2 concentrations during other FHD prescriptions.…”

“…In this work, we have used a mass balance analysis of a mathematical model of bicarbonate kinetics with bicarbonate and lactate as dialysate buffer bases to extrapolate the previous findings from the FREEDOM study to other FHD treatment prescriptions. The HD treatment prescriptions studied were chosen to be representative of those used in current clinical practice (internal data from NxStage Medical) and in recent literature 3 …”

“…This series examined four and five treatments per week using dialysate volumes of 60 L for 210 minutes and 50 L for 180 minutes, respectively; by design, these prescriptions used 240 to 250 L of dialysate volume per week. The third series examined the effect of treatment frequency during FHD for long treatment times of 400 minutes and low blood flow rates (300 mL/min), those more typical for nocturnal HD 3 . This series examined 3.5 (every‐other‐day), four and five treatments per week using dialysate volumes of 60 L for each treatment.…”

“…In a retrospective cross‐sectional study of 284 patients who transferred from thrice‐weekly in‐center HD (ICHD) to daily home HD during the FREEDOM Study, Leypoldt et al 2 reported that daily home HD for 3 months resulted in a mean decrease of 1.0 mEq/L in serum tCO 2 concentration when using a dialysate lactate concentration of 40 mEq/L but a mean increase of 2.5 mEq/L when using a dialysate lactate concentration of 45 mEq/L. Very recently, Gangaram et al 3 reported biochemical data on 20 patients from four dialysis centers in Europe treated by nocturnal home HD using the NxStage System One. The prescription was either HD every‐other‐night or 4 or 5 times per week with over half of the patients treated using 60 L of dialysate per treatment.…”