I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: General Discussion => Topic started by: Hemodoc on April 03, 2011, 01:56:11 PM
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By Peter Laird, MD
In-center conventional dialysis as practiced in America results in an average survival of about 40% over a five year period of time depending on which survey is looked at. The results of our rapid ultrafiltration rates and short treatment times thrice weekly is only a shadow of the original treatments times of 8-9 hours thrice weekly developed by the pioneers of dialysis. The survival of common cancers and even HIV are actually better than the outcomes of American style, in-center dialysis care.
Nearly 50 years later, the wisdom of longer duration or more frequent dialysis prevails. Many entering into the world of dialysis are confronted with the knowledge of our dreadful survival statistics and look for alternative treatment options. One such option that many choose is short daily hemodialysis in the comfort of their own homes, dialysis 5-7 days a week for 2-3.5 hours at a time. The good news is that observational studies show excellent outcomes with this treatment option.
Short daily haemodialysis: survival in 415 pateints treated for 1006 patient-years
Results. Eighty-five patients (20%) died; 5-year cumulative survival was 68 ± 4.1% and 10-year survival was 42 ± 9%. Age, secondary renal failure and in-centre dialysis were associated with
mortality, while gender, frequency of dialysis (5, 6 or 7 per week), continent, country and blood access were not. Survival was compared with matched patients from the USRDS 2005 Data Report using the standardized mortality ratio and cumulative survival curves. Both comparisons showed that the survival of the daily haemodialysis patients was 2–3 times higher and the predicted 50% survival time 2.3–10.9 years longer than that of the matched US haemodialysis patients. Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants.
Conclusions. Survival of patients on short daily haemodialysis was 2–3 times better than that of matched three times weekly haemodialysis patients reported by the USRDS.
Returning to optimal dialysis strategies as first practiced in America supplying patients with more frequent and longer duration dialysis breaks the cycle of death and suffering that in-center dialysis patients encounter today. While we have no true cures for ESRD, there is excellent data to promote the use of short daily dialysis over the conventional treatments. The Frequent Hemodialysis Network Trial Group followed their cohort of patients for 12 months likewise showing a significant benefit, yet we continue to fail to provide only a fraction of American patients optimal dialysis today. After 50 years of consistent efficacy, alternative treatment options should become the standard treatment offered to all eligible patients.
http://www.hemodoc.com/2011/04/what-is-the-expected-lifespan-on-short-daily-dialysis.html
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By Peter Laird, MD
The survival [rates] of... HIV are actually better than the outcomes of American style, in-center dialysis care.
http://www.hemodoc.com/2011/04/what-is-the-expected-lifespan-on-short-daily-dialysis.html
Okay, that's just obscene. How did the system get that far off course?
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Would there be any difference between 4 hours 3 days a week and 3½ hours 3 days a week? I ask this because I recently had my time reduced because of my job times and the nephrologist said my clearance would be better if I did the 4 hours.
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I am not sure about this statement:
"Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants."
The graft of deceased donor transplants has about 11-13 years (average). All deceased donor transplant patient survival rates in the U.S. (Non-ECD) is 85.5% for five years and 64.8% for 10 years, much higher than 68% and 42% in this report. The long-term transplant survival rate will be improved in the future, since the short-term survival rates have been improved during the recent years. The 68% and 42% are more comparable with transplant patients of 65+ age group, which are only a small portion of transplant patients.
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Would there be any difference between 4 hours 3 days a week and 3½ hours 3 days a week? I ask this because I recently had my time reduced because of my job times and the nephrologist said my clearance would be better if I did the 4 hours.
Dear Bajanne, there is a significant benefit for each 30 minute incremental increase in dialysis session length even when looked at in traditional in-center thrice weekly protocols. When it comes to dialysis, the more the better.
I wrote a post on another Kjellstrand article showing this effect.
http://www.hemodoc.com/2011/01/short-daily-dialysis-can-be-too-short.html
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I am not sure about this statement:
"Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants."
The graft of deceased donor transplants has about 11-13 years (average). All deceased donor transplant patient survival rates in the U.S. (Non-ECD) is 85.5% for five years and 64.8% for 10 years, much higher than 68% and 42% in this report. The long-term transplant survival rate will be improved in the future, since the short-term survival rates have been improved during the recent years. The 68% and 42% are more comparable with transplant patients of 65+ age group, which are only a small portion of transplant patients.
Dear Jie, the slide by Dr. Kjellstrand is looking at a portion of the 415 patients in the article, a subgroup that he has himself which had a bit higher survival than the total cohort of 415. Most people do not equate equal survival with short daily dialysis to transplant even though it was comparable in the cohort by Kjellstrand in his slide. However, Pauly, et al showed equal survival between nocturnal daily dialysis and cadaveric transplant, but not as good as living donor transplants. I will post that tomorrow hopefully.
The take home message of this article and the FHN study is the significant improvement in survival with daily dialysis over the usual in-center thrice weekly data as evidenced in the 40% 5 year survival in the USRDS data tables even when looking at nearly the same number of total hours per week vs the 85% 5 year survival of short daily dialysis. As they state, 2-3 times better survival than the USRDS data. Lastly, the results were age matched as you alluded to but you are looking at the entire transplant population. The main point once again is using the transplant rates as the gold standard to compare showing the significant improvement of short daily dialysis compared to the conventional hemodialysis in-center. More is better, the closer we can get to the best treatment options, the better. Short daily dialysis starts us on that journey but is not the best that we can do with dialysis options. More on the nocturnal dialysis data compared directly to transplant later.
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I am not sure about this statement:
"Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants."
The graft of deceased donor transplants has about 11-13 years (average). All deceased donor transplant patient survival rates in the U.S. (Non-ECD) is 85.5% for five years and 64.8% for 10 years, much higher than 68% and 42% in this report. The long-term transplant survival rate will be improved in the future, since the short-term survival rates have been improved during the recent years. The 68% and 42% are more comparable with transplant patients of 65+ age group, which are only a small portion of transplant patients.
Dear Jie, the slide by Dr. Kjellstrand is looking at a portion of the 415 patients in the article, a subgroup that he has himself which had a bit higher survival than the total cohort of 415. Most people do not equate equal survival with short daily dialysis to transplant even though it was comparable in the cohort by Kjellstrand in his slide. However, Pauly, et al showed equal survival between nocturnal daily dialysis and cadaveric transplant, but not as good as living donor transplants. I will post that tomorrow hopefully.
I have modiified my post to show that the slide by Dr. Kjellstrand and the article quoted are two separate articles and a different cohort. The first is 415 patients, the second comes from another study with 265 patients.
The take home message of these articles and the FHN study is the significant improvement in survival with daily dialysis over the usual in-center thrice weekly data as evidenced in the 40% 5 year survival in the USRDS data tables even when looking at nearly the same number of total hours per week vs the 85% 5 year survival of short daily dialysis. As they state, 2-3 times better survival than the USRDS data. Lastly, the results were age matched as you alluded to but you are looking at the entire transplant population. The main point once again is using the transplant rates as the gold standard to compare showing the significant improvement of short daily dialysis compared to the conventional hemodialysis in-center. More is better, the closer we can get to the best treatment options, the better. Short daily dialysis starts us on that journey but is not the best that we can do with dialysis options. More on the nocturnal dialysis data compared directly to transplant later.
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Great Post.... Information is greatly appreciated