Short Daily Dialysis Can be Too Short

[Hemodoc]

Short Daily Dialysis Can be Too Short
By Peter Laird, MD

The Frequent Hemodialysis Network Trial Group results published in November 2010 has focused many providers interest in short daily dialysis since the results of this randomized and controlled trial dramatically showed the benefits of short daily dialysis. The study endpoints of reduced LVH and improved physical-health composite score is a long awaited result from a randomized and controlled trial.  In addition, the long standing argument of how much dialysis and at what dose is best for patients stands on the side of the dozens of observational studies showing a benefit to more frequent and longer duration dialysis.  The gold standard of dialysis care is daily, nocturnal dialysis of 6-8 hours duration done at low blood flow and low ultrafiltration rates.

The NxStage System One portable home dialysis machine introduced a new wave of interest in home based therapies especially in the last five years.  Many now use the NxStage machine as short daily hemodialysis.  Combined with the ease of learning and using this system, patients are now free to dialyze in the comfort of their own home. However, many patients will be tempted to shorten their daily treatments to augment lifestyle changes and freedom.  Dr. Kjellstrand, et al published an important paper in September 2010 looking at the total weekly duration of dialysis and mortality. They found that sometimes, short daily dialysis can be too short:

Survival with short-daily hemodialysis: Association of time, site, and dose of dialysis

Short-daily hemodialysis can be too short. In this series of patients, every extra hour spent on dialysis was associated with better survival. This finding is in agreement with those of others analyzing thrice-weekly dialysis5–8 and interestingly is seen even in patients treated by long night hemodialysis, where the weekly dialysis hours are 2 to 4 times longer than in our patients on SDHD.12

Patients considering home hemodialysis should bear in mind that time on dialysis correlates directly to survival.  For those considering short daily dialysis, avoiding total dialysis times less than 15 hours each week should be in the forefront of discussions with your medical team.  When coupled with the information of the FHN showing more frequent dialysis benefits, the optimal approach is to maximize time and frequency of sessions individualized to patients schedules and lifestyles.  We are once again coming full circle back to Dr. Scribner's wisdom of the Hemodialysis Product where he correlated survival based on a simple calculation of frequency and time on dialysis back in 2002.

http://www.hemodoc.com/2011/01/short-daily-dialysis-can-be-too-short.html

[Zach]

Excellent point, Hemodoc!

Unfortunately, the folks at NxStage seem to be promoting 2.5 hours per treatment, five times a week.
Perhaps not such a good idea after all.

[monrein]

Even though I did short daily myself I totally agree that longer ought to be the norm.  Had it not been for the fact that I had a transplant scheduled, I would have asked to go to nocturnal at home.

[KICKSTART]

My neph once told me i was the sort of person that would benefit more from 2 hours per day every day , than the normal 4 hours every other day. I often wonder does the benefit you get from hemo depend on the type you are , like the difference in transporters on pd ?

[Bill Peckham]

Excellent point, Hemodoc!

Unfortunately, the folks at NxStage seem to be promoting 2.5 hours per treatment, five times a week.
Perhaps not such a good idea after all.

 

Agreed on all points.

[Hemodoc]

My neph once told me i was the sort of person that would benefit more from 2 hours per day every day , than the normal 4 hours every other day. I often wonder does the benefit you get from hemo depend on the type you are , like the difference in transporters on pd ?

Not sure what he would base that statement on since all patients will benefit from more frequent and longer duration dialysis.  Unfortunately, there is not enough attention paid to dialysis during most nephrology training programs.  On the other hand, the FHN was 2 hours, 6 times a week vs 4 hours 3 times a week, same amount of time on the machine, but outcomes were much better with higher frequency.  Both frequency and duration matters clinically.

[Bill Peckham]

My neph once told me i was the sort of person that would benefit more from 2 hours per day every day , than the normal 4 hours every other day. I often wonder does the benefit you get from hemo depend on the type you are , like the difference in transporters on pd ?

Not sure what he would base that statement on since all patients will benefit from more frequent and longer duration dialysis.  Unfortunately, there is not enough attention paid to dialysis during most nephrology training programs.  On the other hand, the FHN was 2 hours, 6 times a week vs 4 hours 3 times a week, same amount of time on the machine, but outcomes were much better with higher frequency.  Both frequency and duration matters clinically.

That's Scribner's hemodialysis product in action. The first hour of dialysis is the most efficient, it is when the solute concentrations are highest in the blood thus with a steeper gradiant more solutes cross the semipermeable membrane and into the dialysate.


HDP 3dx/week 4hr/dx = 9 x 4 = 36
HDP 6dx/week 2hr/dx = 36 x 2 = 72

[Rerun]

Some people just don't want to sit very long.  That is why nocturnal is good..... you have to sleep anyway, why not multi-taks.  But, some people I've talked to just are not interested.

Just like smoking is bad for you but some people still do it......  longer dialysis is better for you and some people are just not going to do it.

But they at least should be given the information to decide for themselves.

[MooseMom]

I don't wanna sit for very long, either.

BUT, I do want to be a healthy MooseMom, and if an extra hour a day will keep me much healthier, hell, I'm on the damn machine anyway (well, I will be at some point).

More people than ever are NOT smoking because they're enlightened.  More education for people on dialysis or with dialysis in their future might encourage them to make a healthier choice.

[del]

Nocturnal is the gold standard of dialysis!!!  Hubby tried short daily for a while.  he went back to nocturnal because his phos and potassium was not so well controlled with short daily - he still had to take binders.  He also didn't like giving up a big part of his day for dialysis. At least when he hooks up night time he can sleep.  His labs are really good with the nocturnal

[Zach]

That's Scribner's hemodialysis product in action. The first hour of dialysis is the most efficient, it is when the solute concentrations are highest in the blood thus with a steeper gradiant more solutes cross the semipermeable membrane and into the dialysate.


HDP 3dx/week 4hr/dx = 9 x 4 = 36
HDP 6dx/week 2hr/dx = 36 x 2 = 72

That's true for most small weight solutes such as urea, but phosphorus as well as the larger middle weight solutes are time dependent.

[Hemodoc]

That's Scribner's hemodialysis product in action. The first hour of dialysis is the most efficient, it is when the solute concentrations are highest in the blood thus with a steeper gradiant more solutes cross the semipermeable membrane and into the dialysate.


HDP 3dx/week 4hr/dx = 9 x 4 = 36
HDP 6dx/week 2hr/dx = 36 x 2 = 72

That's true for most small weight solutes such as urea, but phosphorus as well as the larger middle weight solutes are time dependent.

True enough, and that is in many ways part of the point of the article in question as the basis of this post.  More frequent and longer duration is where it is at just as Dr. Scribner noted.  If anyone has not yet looked at his Hemodialysis Product paper, I did link to it in my post, but here is the link for IHD.

http://www.therenalnetwork.org/qi/resources/HDP.pdf

[greg10]

That's Scribner's hemodialysis product in action. The first hour of dialysis is the most efficient, it is when the solute concentrations are highest in the blood thus with a steeper gradiant more solutes cross the semipermeable membrane and into the dialysate.


HDP 3dx/week 4hr/dx = 9 x 4 = 36
HDP 6dx/week 2hr/dx = 36 x 2 = 72

That's true for most small weight solutes such as urea, but phosphorus as well as the larger middle weight solutes are time dependent.

True enough, and that is in many ways part of the point of the article in question as the basis of this post.  More frequent and longer duration is where it is at just as Dr. Scribner noted.  If anyone has not yet looked at his Hemodialysis Product paper, I did link to it in my post, but here is the link for IHD.

http://www.therenalnetwork.org/qi/resources/HDP.pdf

Thank you all.  I was wondering what kind of new math you were doing 
before reading the  Scribner paper again 

The Hemodialysis Product
Based on published evidence from many sources, we propose a new index of adequacy of hemodialysis, to be called the
Hemodialysis Product (HDP). This new index incorporates dialysis frequency, which is an important variable:

HDP = (hrs/dialysis session) x (sessions/wk)^2

[Zog]

Does nocturnal dialysis result in shorter fistula life?  Things to worry about if you plan on doing this decades.

[okarol]

Nocturnal is the gold standard of dialysis!!!  Hubby tried short daily for a while.  he went back to nocturnal because his phos and potassium was not so well controlled with short daily - he still had to take binders.  He also didn't like giving up a big part of his day for dialysis. At least when he hooks up night time he can sleep.  His labs are really good with the nocturnal

I forget - is he doing 3 nights a week?

[Hemodoc]

Does nocturnal dialysis result in shorter fistula life?  Things to worry about if you plan on doing this decades.

Access issues are always one of the things to focus on with any discussion of more frequent dialysis.  In the FHN, there was an increased risk of vascular access events, but two things must be considered, first, it was incenter with mainly techs and nurses, not all self cannulating and second, they didn't report on the number of patients with buttonhole cannulation.

Many observational studies have looked a buttonholes and increased, daily use without any undo increased complications.  Self cannulation with buttonholes may help protect the fistula especially from aneurysms.  There is a trend to more frequent infections.

On an anecdotal level, I have had a functioning buttonhole on my arterial access site for 3.5 years without any access issues whatsoever.  I take great pains to adhere to very strict disinfection before cannulating the needles.  I suspect that some of the increased infections with buttonholes is technique related.  I only use sterile supplies, not just clean and all separately packaged.  I use sterile, disposable tweezers for each buttonhole and I don't use the same equipment on both sites at the same time to prevent cross contamination if it exists in one.

I take a shower just before hooking up, then when picking the scabs, I clean the whole area with alcohol and in between each hole.  When cannulating, I once again start with an alcohol swab, then I go to betadine since it doesn't cause any skin reactions and the other options do.  I use two swabs and let it dry completely using a circular motion from inner to outer without going back inside.  This is the technique I was taught in medical school surgery rotation for office procedures.  Then, I take 4 alcohol pads and remove the excess betadine in the involved area.  I was always taught that betadine is irritating to the tissues so I carefully remove it with alcohol swabs after it is completely dry.  Then I cannulate without any undue delay.

If I contaminate the area accidently, I start with one betadine swab and then back to the alcohol.

Betadine may not be ideal for you but it does work well to date for my needs.

Technique and careful attention to detail is what it takes in my opinion to make the buttonhole work.  Careful inspection of the buttonhole for any redness or puss would mandate that you consider another site with a sharp for that day until it resolves. I have only had to do that a couple of times in nearly 4 years.  Understanding the signs and symptoms of an early infection is key and you may wish to get instruction in this from your medical team.  As always, if you have any questions about this, call your team right away.  Having taken care of skin infections for years, I am already attuned to that issue.

There is much to learn, but once you have mastered the different aspects of self cannulation and buttonholes, the whole process is actually fairly simple, but you must be quite diligent and rigorous in infection control.  i hope that this is useful information to discuss with your own health care team.

[del]

Nocturnal is the gold standard of dialysis!!!  Hubby tried short daily for a while.  he went back to nocturnal because his phos and potassium was not so well controlled with short daily - he still had to take binders.  He also didn't like giving up a big part of his day for dialysis. At least when he hooks up night time he can sleep.  His labs are really good with the nocturnal

I forget - is he doing 3 nights a week?

Hubby does 5 nights a week but rarely takes 2 nights in a row.  He had to last week because he had a night off and the next night we had a problem with the machine.  He usually does 3 nights, 1 off, 2 nights , 1 off then back to 3 nights.

[Stoday]

Does nocturnal dialysis result in shorter fistula life?  Things to worry about if you plan on doing this decades.

A more recent paper (Dec 2010) comparing 6X a week with 3X concluded Frequent hemodialysis, as compared with conventional hemodialysis, was associated with favorable... (mortality) ...results but prompted more frequent interventions related to vascular access. http://www.nejm.org/doi/full/10.1056/NEJMoa1001593

I'm not sure what's meant by interventions related to vascular access but I suspect sloppy access cleaning, as suggested by Hemodoc, is a significant factor. I did find Hemodoc's description of his cleaning procedure to be very helpful..

[okarol]

Nocturnal is the gold standard of dialysis!!!  Hubby tried short daily for a while.  he went back to nocturnal because his phos and potassium was not so well controlled with short daily - he still had to take binders.  He also didn't like giving up a big part of his day for dialysis. At least when he hooks up night time he can sleep.  His labs are really good with the nocturnal

I forget - is he doing 3 nights a week?

Hubby does 5 nights a week but rarely takes 2 nights in a row.  He had to last week because he had a night off and the next night we had a problem with the machine.  He usually does 3 nights, 1 off, 2 nights , 1 off then back to 3 nights.

Thanks del. I know other patients do in-center nocturnal so its 3 days, but 6 hours, I think. How many hours does Walt do?

[Desert Dancer]

There is a trend to more frequent infections.

Thank you for sharing your technique, Hemodoc; I am always looking for ways to improve/tighten up my own technique. I would just like to add - if I may - that a face mask is also an absolute must for buttonholes. In my clinic, the nurses expressed a desire for their buttonhole patients to use face masks, but they did not require it and not everyone used them. I think there is a perception that face masks are only really necessary for catheters but this couldn't be further from the truth.

[Hemodoc]

There is a trend to more frequent infections.

Thank you for sharing your technique, Hemodoc; I am always looking for ways to improve/tighten up my own technique. I would just like to add - if I may - that a face mask is also an absolute must for buttonholes. In my clinic, the nurses expressed a desire for their buttonhole patients to use face masks, but they did not require it and not everyone used them. I think there is a perception that face masks are only really necessary for catheters but this couldn't be further from the truth.

Sorry, yes you are right.  I always use a face mask as does my wife when we hook up.  In addition, I leave my pressure dressing on for two hours and then when I take that off, I remove my spent bandaide and place a clean one after cleaning up the excess betadine with a couple of alcohol pads.  We also use plenty of alcohol hand gel during our hookup as well.  I believe it is a confluence of factors that help over come a real infection risk.  I would never go so far to state you can prevent 100% of all infections, but I think we can do a lot better than the current state of affairs.  After all, we are accessing the vascular compartment directly, hemodialysis is an invasive procedure, well tolerated and as far as invasive procedures go when done with care and thoughfulness quite safe, nevertheless, we should never lose sight of the fact that we are in a sense invading the vascular compartment and things can go wrong quite readily without a great deal of care and attention to details.  Following a preset check list helps avoid many of the alarms folks get into and other complications.  In this case, practice makes perfect, or as perfect as us people can be that is. 

Slow down, take your time and do things right.  If you notice you contaminate something along the way, discard that item and start with a fresh and clean one. I dropped the red line just when we were getting ready to hook up on the final step, I had no choice, I started the whole setup all over again.  You just can't take undo risks with this treatment.  I suspect some folks just over look a "minor" contamination and then pay for it later.  Remember, the first place the blood goes from your arm is directly through the heart where the heart valves are very susceptible to infection.  A heart valve infection is potentially life threatening very quickly.  So, just be careful out there and realize these complications although quite real, are fortunately, quite rare when proper infection control techniques are utilized every dialysis session.

[del]

Nocturnal is the gold standard of dialysis!!!  Hubby tried short daily for a while.  he went back to nocturnal because his phos and potassium was not so well controlled with short daily - he still had to take binders.  He also didn't like giving up a big part of his day for dialysis. At least when he hooks up night time he can sleep.  His labs are really good with the nocturnal

Walt does 7 hours a night.

I forget - is he doing 3 nights a week?

Hubby does 5 nights a week but rarely takes 2 nights in a row.  He had to last week because he had a night off and the next night we had a problem with the machine.  He usually does 3 nights, 1 off, 2 nights , 1 off then back to 3 nights.

Thanks del. I know other patients do in-center nocturnal so its 3 days, but 6 hours, I think. How many hours does Walt do?