The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial

Abstract

Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/Vurea, a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Thus, we were unable to demonstrate a definitive benefit of more frequent nocturnal hemodialysis for either coprimary outcome.

Assessment and Management of Hypertension in Patients on Dialysis

“…122 Improvement in SBP was also noted in the companion FHN Nocturnal trial. 123 Increasing the treatment duration may improve hemodynamic stability of dialysis and make the procedure more tolerable, but it is not a requirement for improvement in left ventricular mass. Shortening the procedure to tailor dialysis to a minimum Kt/V may provoke intradialytic symptoms, postdialysis fatigue, and nonadherence to therapy; thus, this is not recommended.…”

Intensive Hemodialysis

“…Progression of kidney disease has been studied in both observational and clinical trial settings. [1][2][3][4][5][6][7] However, there has been considerable variability in progression reported, ranging from rapid progression to nonprogressive stable kidney function to an improvement in kidney function over time. 2,[6][7][8] Recent studies that attempted to characterize patients who experience an improvement in kidney function were plagued by the variability inherent in serum creatinine measurements used to estimate GFR.…”

“…2,3 More recently, the Frequent Hemodialysis Network (FHN) trials of daily and nocturnal dialysis were conducted to test the hypothesis that more radical modifications in hemodialysis treatment time and/or frequency would improve patient outcomes. 4,5 The FHN trials were designed to examine the effects of treatment on a composite of mortality, change in left ventricular mass change, and change in self-reported physical functioning. There was also a range of secondary outcomes that were evaluated in these studies.…”

Clinical Effects of Personalized Dialysate Sodium in Conventional, Quotidian, and Nocturnal Home Hemodialysis Patients: A Randomized Crossover Trial

“…Considerable research has evaluated the effect of dialysis frequency and duration on clinical outcomes [6,[13][14][15]. It is well established that longer haemodialysis sessions improve outcomes [13,14,[16][17][18][19] including mortality [20][21][22]. How this improvement relates to volume and pressure control remains controversial.…”

“…A chronic state of volume and pressure overload is a major contributor [2][3][4][5] leading to hypertension, left ventricular hypertrophy [6][7][8][9][10], and death [11,12]. Considerable research has evaluated the effect of dialysis frequency and duration on clinical outcomes [6,[13][14][15]. It is well established that longer haemodialysis sessions improve outcomes [13,14,[16][17][18][19] including mortality [20][21][22].…”