Outcomes Associated with In-Center Nocturnal Hemodialysis from a Large Multicenter Program

Lacson, Eduardo; Wang, Weiling; Lester, Keith S.; Ofsthun, Norma J.; Lazarus, J. Michael; Hakim, Raymond M.

doi:10.2215/cjn.06070809

Cited by 63 publications

(76 citation statements)

References 20 publications

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“…1,2 Lengthening dialysis session times to .5.5 hours provides substantially greater solute clearance and extracellular fluid volume control, potentially leading to improved outcomes. [3][4][5] Unfortunately, there are no randomized trials evaluating the effects of extended hours hemodialysis regimens on survival. Previous observational studies have suggested that lengthening hemodialysis session time to .6 hours, and increasing frequency to $5 treatments per week may be associated with improved survival.…”

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confidence: 99%

Intensive Hemodialysis Associates with Improved Survival Compared with Conventional Hemodialysis

Nesrallah

Lindsay

Cuerden

et al. 2012

Journal of the American Society of Nephrology

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189

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Patients undergoing conventional maintenance hemodialysis typically receive three sessions per week, each lasting 2.5-5.5 hours. Recently, the use of more intensive hemodialysis (.5.5 hours, three to seven times per week) has increased, but the effects of these regimens on survival are uncertain. We conducted a retrospective cohort study to examine whether intensive hemodialysis associates with better survival than conventional hemodialysis. We identified 420 patients in the International Quotidian Dialysis Registry who received intensive home hemodialysis in France, the United States, and Canada between January 2000 and August 2010. We matched 338 of these patients to 1388 patients in the Dialysis Outcomes and Practice Patterns Study who received in-center conventional hemodialysis during the same time period by country, ESRD duration, and propensity score. The intensive hemodialysis group received a mean (SD) 4.8 (1.1) sessions per week with a mean treatment time of 7.4 (0.87) hours per session; the conventional group received three sessions per week with a mean treatment time of 3.9 (0.32) hours per session. During 3008 patient-years of follow-up, 45 (13%) of 338 patients receiving intensive hemodialysis died compared with 293 (21%) of 1388 patients receiving conventional hemodialysis (6.1 versus 10.5 deaths per 100 personyears; hazard ratio, 0.55 [95% confidence interval, 0.34-0.87]). The strength and direction of the observed association between intensive hemodialysis and improved survival were consistent across all prespecified subgroups and sensitivity analyses. In conclusion, there is a strong association between intensive home hemodialysis and improved survival, but whether this relationship is causal remains unknown.

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confidence: 99%

Intensive Hemodialysis Associates with Improved Survival Compared with Conventional Hemodialysis

Nesrallah

Lindsay

Cuerden

et al. 2012

Journal of the American Society of Nephrology

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189

170

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“…7 In the last few years, better laboratory and patient outcomes have been observed with three times per week in-center nocturnal hemodialysis (INHD) performed for more than 5.5 hours (generally about 8 hours) compared with three times per week conventional hemodialysis (CHD) performed for 3.0-5.5 hours. [8][9][10][11][12][13][14][15][16] The reports were mostly from single centers, with comparisons made between cohorts or using a crossover design within the same patients. As in all observational studies, selection bias, survival bias, and other limitations must temper interpretation of the findings.…”

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confidence: 99%

“…15 While maintaining an observational cohort design in the current study, we addressed concerns about our prior report in two ways. (1) We modified patient inclusion criteria as solely based on initial (i.e., first-ever) conversion from CHD to INHD.…”

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confidence: 99%

Survival with Three-Times Weekly In-Center Nocturnal Versus Conventional Hemodialysis

Lacson

Suri

et al. 2012

Journal of the American Society of Nephrology

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Whether the duration of hemodialysis treatments improves outcomes remains controversial. Here, we evaluated survival and clinical changes associated with converting from conventional hemodialysis (mean=3.75 h/treatment) to in-center nocturnal hemodialysis (mean=7.85 h/treatment). All 959 consecutive patients who initiated nocturnal hemodialysis for the first time in 77 Fresenius Medical Care facilities during 2006 and 2007 were eligible. We used Cox models to compare risk for mortality during 2 years of follow-up in a 1:3 propensity score-matched cohort of 746 nocturnal and 2062 control patients on conventional hemodialysis. Two-year mortality was 19% among nocturnal hemodialysis patients compared with 27% among conventional patients. Nocturnal hemodialysis associated with a 25% reduction in the risk for death after adjustment for age, body mass index, and dialysis vintage (hazard ratio=0.75, 95% confidence interval=0.61-0.91, P=0.004). With respect to clinical features, interdialytic weight gain, albumin, hemoglobin, dialysis dose, and calcium increased on nocturnal therapy, whereas postdialysis weight, predialysis systolic blood pressure, ultrafiltration rate, phosphorus, and white blood cell count declined (all P,0.001). In summary, notwithstanding the possibility of residual selection bias, conversion to treatment with nocturnal hemodialysis associates with favorable clinical features, laboratory biomarkers, and improved survival compared with propensity score-matched controls. The potential impact of extended treatment time on clinical outcomes while maintaining a three times per week hemodialysis schedule requires evaluation in future clinical trials.

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“…It has been demonstrated that longer dialysis with slower ultrafiltration rates allows greater salt and water removal from patients without inducing profound hypotensive episodes (72)(73)(74). Long overnight or nocturnal dialysis performed thrice per week for patients with a history of frequent and large interdialytic fluid gains (unresponsive to conventional "short" treatments) improves BP and fluid control (75,76). Thus, longer TT with slower rates of ultrafiltration and with lower dialysate sodium may be an important contributor to both wellbeing and survival in dialysis patients.…”

Section: Rationale For Renewed Interest In Treatment Timementioning

confidence: 99%

“…Despite a relatively narrow range of TT (majority between 3 and 4.5 hours, with the exception of nocturnal dialysis), recent observational studies have demonstrated relative greater comparative survival and less hospitalization with longer dialysis three times a week (69,(83)(84)(85)(86). Data from the United States, Europe, and Japan where the majority of patients dialyzed for Ͻ4 hours, indicated that beyond Kt/V, TT of Ͼ4 hours was significantly associated with lower adjusted relative risk of death (0.81, P ϭ 0.0005) (69).…”

Section: Re-evaluating Outcomes Associated With Treatment Timementioning

confidence: 99%

Hemodialysis Treatment Time

Lacson

Brunelli

2011

Clinical Journal of the American Society of Nephrology

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SummaryHistorical, clinical, economic, and technological developments have driven a shift in clinical practice from predominantly 6-hour-long hemodialysis treatments to much shorter treatment times that are prevalent today. Patients, physicians, and providers had considered shortening dialysis treatments as a means to decrease the overall burden imposed by this necessary life-saving therapy. However, shorter dialysis is not a panacea and may engender trade-offs in terms of patient morbidity and mortality. We examine the literature with the benefit of hindsight and in light of recent studies that have improved understanding of the complex relationship between dialysis dose and outcome. We touch upon the role of dialysis frequency relative to treatment time. We conclude with the suggestion that a new treatment paradigm should consider a minimum adequate dialysis treatment time of 4 hours for the majority of patients, with anything shorter becoming the exception rather than the rule.

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Outcomes Associated with In-Center Nocturnal Hemodialysis from a Large Multicenter Program

Cited by 63 publications

References 20 publications

Intensive Hemodialysis Associates with Improved Survival Compared with Conventional Hemodialysis

Intensive Hemodialysis Associates with Improved Survival Compared with Conventional Hemodialysis

Survival with Three-Times Weekly In-Center Nocturnal Versus Conventional Hemodialysis

Hemodialysis Treatment Time

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