Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study

Murea, Mariana; Patel, Ashish; Highland, Benjamin R.; Yang, Weiyi; Fletcher, Alison; Kalantar‐Zadeh, Kamyar; Dressler, Emily V.; Russell, Gregory B.

doi:10.1053/j.ajkd.2021.12.001

Cited by 25 publications

(32 citation statements)

References 37 publications

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“…B-type natriuretic peptide was predictor of mortality in HD patients. 2021 (0.75) Murea/USA 50 23 25 Clearance > 2 mL/min MCT RCT Preliminary results show 2x-HD confers better preservation of residual kidney function. All patients were switched to 3x-HD at week 7.…”

Section: Outcomes Datamentioning

confidence: 99%

“…Recently, a randomized controlled trial compared 25 patients, who were initiated on twice weekly hemodialysis with adjuvant medical therapy including patiromer for 6 weeks prior to transitioning to thrice weekly dialysis to 23 patients that had a conventional thrice weekly start. 50 All patients were adults who had GFR of > 5 mL/min and urine output > 500 mL/day. At 24 weeks the need for hospitalization as shown via incidence rate ratio was 0.31 (95% CI 0.08–1.17) and 7 deaths were recorded (1 in the incremental and 6 in the conventional group).…”

Section: Outcomes Datamentioning

confidence: 99%

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Incremental Hemodialysis: What We Know so Far

Soi¹,

Faber²,

Paul³

2022

IJNRD

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Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.

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Section: Outcomes Datamentioning

confidence: 99%

Section: Outcomes Datamentioning

confidence: 99%

Incremental Hemodialysis: What We Know so Far

Soi¹,

Faber²,

Paul³

2022

IJNRD

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“…All participants had received between 3 and 5 HD sessions prescribed thrice-weekly by the treating nephrologist, before randomization. Baseline demographic and clinical data for the two groups have been described in a separate report [21]. Briefly, the cohort had mean (SD) age 61.3 (14.0) years, 44% were women, 56% were Black, 65% had diabetes and 79% were using a central venous catheter at enrollment (Table 1).…”

Section: Participant Characteristicsmentioning

confidence: 99%

“…We undertook the first pilot clinical trial of incremental-start HD in patients with incident KDRD in the US (NCT 03740048). The primary objective of the TWOPLUS pilot clinical trial was to test the feasibility of implementing a schedule of incremental HD at outpatient dialysis facilities using a protocol of blood tests and timed urine collection that was embedded in usual clinical workflow, the results of which were published elsewhere [21]. Exploratory analyses compared patientreported outcomes using three instruments, the results of which are presented here.…”

Section: Introductionmentioning

confidence: 99%

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

et al. 2022

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Background Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden. Methods The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group). Results The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD. Conclusions This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations. Trial registration Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018.

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“…A unique pilot study on patients undergoing hemodialysis twice weekly, as opposed to standard thrice weekly dialysis, also include the use of patiromer. 31 Twenty-three patients underwent twice weekly dialysis, of which 17% received patiromer during the median follow up of 281 days. In this group it was significant for better urine outputs and better urea and creatinine clearance.…”

Section: Introductionmentioning

confidence: 99%

Clinical Efficacy, Safety, Tolerability, and Real-World Data of Patiromer for the Treatment of Hyperkalemia

Colbert¹,

Sannapaneni²,

Lerma³

2022

DHPS

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Hyperkalemia remains one of the most difficult consequences of disease state and treatment for patients with chronic kidney disease, heart failure, and diabetes. Controlling hyperkalemia can be difficult, but has become easier with the introduction of novel oral potassium binders. Patiromer was approved in 2015 for the treatment of hyperkalemia by the FDA in the United States. Several pivotal trials proved its efficacy, safety, and improved tolerability compared with previous hyperkalemia treatments. Additionally, many real-world publications and trials have given deeper insights into the capabilities of patiromer. We discuss improved disease state outcomes with combining patiromer with RAASi. This paper will also highlight new trials forthcoming that are highly anticipated to expand the possibilities in using patiromer to improve outcomes and populations.

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Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study

Cited by 25 publications

References 37 publications

Incremental Hemodialysis: What We Know so Far

Incremental Hemodialysis: What We Know so Far

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

Clinical Efficacy, Safety, Tolerability, and Real-World Data of Patiromer for the Treatment of Hyperkalemia

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