Twice-Weekly Dialysis May Preserve Residual Kidney Function

[kickingandscreaming]

Twice-Weekly Dialysis May Preserve Residual Kidney Function

Patients with preserved residual kidney function experience a survival benefit.

Incremental hemodialysis (HD)—the initiation of HD at lower frequency—may be a safe treatment regimen for incident HD patients with substantial residual kidney function (RKF), according to a new study. In these patients, incremental HD is associated with greater preservation of RKF, investigators reported.

In a study of 23,645 HD patients, a research team led by Kamyar Kalantar-Zadeh, MD, MPH, PhD, of the University of California Irvine, compared incremental HD—whereby patients were placed on routine twice-weekly HD for more than 6 continuous weeks during the first 91 days upon transition to dialysis—with conventional thrice-weekly HD. The incremental HD group included 351 patients. Baseline renal urea clearance and urine volume were higher in these patients in the first patient-quarter compared with the 23,294 patients in the conventional group. The incremental regimen was associated with an average 17-minute shorter dialysis treatment time, less weekly cumulative percentage interdialytic weight gain (IDWG), and lower standard Kt/V. The prevalence of patients with 2.1 or higher total standard Kt/V—the recommended minimum level of urea removed according to National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines—was greater than 95% in patients with a renal urea clearance greater than 3.0 mL/min/1.73 m2 regardless of HD schedule, but differed greatly between schedules among patients with renal urea clearance of 3.0 mL/min/1.73 m2 or less (30% in the incremental group vs. 90% in the conventional group).

Investigators matched the 351 incremental patients with 8,068 conventional HD patients according to baseline renal urea clearance, urine volume, age, sex, diabetes status, and central venous catheter use. Both renal urea clearance and urine volume showed significantly slower declines over time in the incremental versus conventional HD regimens, Dr. Kalantar-Zadeh and colleagues reported online ahead of print in the American Journal of Kidney Diseases.

In survival analyses after year 1, the investigators found no significant difference in all-cause mortality between the incremental and conventional HD groups. Among the incremental HD patients, however, subgroup analyses revealed that the incremental approach was associated with greater mortality risk among patients with inadequate RKF, renal urea clearance of 3.0 mL/min/1.73 m2 or less, and urine volume of 600 mL/day or less, but not among patients with higher baseline RKF.

In addition, results showed a significant trend toward better survival among patients in the incremental group across higher increments of renal urea clearance and lower increments of weekly IDWG, but not in urine volume categories.

“Our results suggest that twice-weekly hemodialysis may be a safe and even preferred regimen to preserve RKF over time following the initiation of maintenance dialysis therapy, especially in patients with substantial RKF,” the authors wrote. “However, caution against twice-weekly hemodialysis may be needed for patients with little or no RKF.”

Dr. Kalantar-Zadeh's group noted that less frequent HD has been commonly prescribed in some other countries, such as China and India. NKF-KDOQI guidelines suggest a twice-weekly schedule for patients with substantial residual renal urea clearance (at least 3.0 mL/min/1.73 m2). In the United States, though, most patients initiating maintenance HD are prescribed thrice-weekly dialysis regardless of RKF.

The researchers pointed out that the estimated glomerular filtration rate is greater than 10 mL/min/1.73 m2 upon initiation of maintenance dialysis in up to 45% of patients in the United States, so the incremental HD regimen may preserve RKF and offer both clinical and economic benefits.

The authors explained that more frequent HD may lead to more rapid loss of RKF through several mechanisms, include the release of nephrotoxic inflammatory mediators during HD and ischemic kidney damage caused by intradialytic hypotension and post-dialytic hypovolemia.
From the March 2016 Issue of Renal And Urology News »http://www.renalandurologynews.com/hemodialysis/twice-weekly-dialysis-may-preserve-residual-kidney-function/article/473604/

[cassandra]

I don't completely understand. What is meant with 'renal urea clearance greater than 3.0 ml/min/1.73 m2 '?  Do people who have a clearance like that actually need dialysis?

[hatedialysis2]

"
The authors explained that more frequent HD may lead to more rapid loss of RKF through several mechanisms, include the release of nephrotoxic inflammatory mediators during HD and ischemic kidney damage caused by intradialytic hypotension and post-dialytic hypovolemia."


THANK YOU!   I have been searching for the past 3.5 years as why my urine output pre-dialysis was normal  and 2-3 months after starting hemodialysis output dwindled to barely 50cc.  I have asked doctors, nurses, researched, nothing came up. One nurse said the kidney "gets lazy" on dialysis, others said its renal failure kicking in.  Lol

[Simon Dog]

My neph told me residual is usually all gone 6 months after starting hemo.

He started me on PD a bit early to preserver residual, but I flunked out into hemo.

[Michael Murphy]

This is going to turn out like the treatment for ulcers, in the 60's almost every one with a ulcer was told drink milk and don't eat spicy food.  A doctor decided that a bacterial infection was responsible for the ulcers, he was laughed at by every member of the medical community.  He continued to treat ulcers with antibiotics and he patients kept being cured, every one else drank milk which helped the bacteria thrive. Today it's generally accepted that antibiotics are the cure. Many things are believed because of the every one knows reason.  Personally I am still eliminating all the fluids I consume. I am about to observe my third year on dialysis.

[Simon Dog]

This is going to turn out like the treatment for ulcers, in the 60's almost every one with a ulcer was told drink milk and don't eat spicy food.  A doctor decided that a bacterial infection was responsible for the ulcers, he was laughed at by every member of the medical community.  He continued to treat ulcers with antibiotics and he patients kept being cured, every one else drank milk which helped the bacteria thrive. Today it's generally accepted that antibiotics are the cure. Many things are believed because of the every one knows reason.  Personally I am still eliminating all the fluids I consume. I am about to observe my third year on dialysis.

Well, my doc did use the word "usually"   

[Michael Murphy]

What is possible is that RKF is reduced by over dialysis, what the study suggests is that for SOME patients less frequent dialysis seems to preserve RKF.  The study also has a kidney measurement that would probably eliminate most patients.  More studies are needed to determine the absolute parameters for 2 times a week dialysis and at what point  to switch the patient to 3 times a week.  This may turn out to be a red herring but further testing will determine if it is a viable option . Another example is the Brazilian thoracic surgeon  who had patients with a enlarged heart that were diieing in the US the only option was a heart transplant. This surgeon figured out how to remove excess heart muscle and fix the problem.  The last I heard his success rate is higher than transplants.  Again when his success was announced most called him a charlatan.   Now his technique has spread around the world.  Knowledge is a growing thing, it's pushed further and faster by those who think out of the box.
.

[hatedialysis2]

It seems like all the medical research and funding in the U.S. goes towards symptom/disease management.   Research for cures seems to be coming out of Europe, Asia and other parts of the world.   
I am seeing more and more research pointing to  viruses causing autoimmune which is linked to autoimmune related CKD, but of course research is non-conclusive.  My guess is these studies do not get the kind of funding that chemotherapy or new machines for kidney disease patients to depend on on. 

I am curious to find out if PD does a better job of preserving RKF when initiating dialysis.   

 

What is possible is that RKF is reduced by ove dialysis,

what is OVE dialysis?

More studies are needed to determine the absolute parameters for 2 times a week dialysis and at what point  to switch the patient to 3 times a week.  .

I would think URR or KT/V along with lab results would be the determining factor for how many times per week.  I know they started me on 3x in center (3.5 hours) and I did not need that much when I started. 

[cassandra]

I was told when I started PD 18 yrs ago that RKF stays longer preserved with PD and I kept producing urine till my dad's kidney was removed after 5 yrs because of complications.

[Michael Murphy]

That was over dialysis, sorry about the typo. Fixed it now the line makes sense.

[TheLivingWater]

I seem to agree that bi-weekly HD is better than tri-weekly HD in terms of preserving RKF. Because HD 3x per week may cause too much dehydration which is bad for the kidney that is trying to preserve it's residual function. But then again it's a case to case basis.

[Vt Big Rig]

I have been on hemo (with NxStage) for eleven months.

I run 4 times a week.

I do still make urine and based on my last 24 hour collection I have not decreased the amount ......... Understanding there is a difference between in center and Nxstge ..... I keep forgetting to ask my neph about this. Cutting out ONE MORE day would be a vacation.

[cassandra]

I have been on hemo (with NxStage) for eleven months.

I run 4 times a week.

I do still make urine and based on my last 24 hour collection I have not decreased the amount ......... Understanding there is a difference between in center and Nxstge ..... I keep forgetting to ask my neph about this. Cutting out ONE MORE day would be a vacation.

 
Hi Vt I think the difference between Nxstage home and which ever machine in-center is that you are not thrice a week squeezed dry to overcome the day off. With any machine at home you only take off what's necessary, and then you still get to stop UF whenever you fancy.

You could try Every Other Day but you'd have to increase the hours per session if you want to keep the same clearance I would think (that would be 3,5 times a week    or 3 x 1 week and 4 x 1 week) Just keep the same amount of hours a week intotal. Sometimes I do 2, sometimes 7, depends on 'life at the day' but I'm aiming for 15 hours a week. (I know that's 2 hrs less than 'perfect' but I really can't be bothered) 

Love, Cas

[Vt Big Rig]

My clearance this last month was 3.2.

I have asked him about the every other day option but he is against it.

I will be changing clinics soon and will very well push some for it there but .... I do like the weekends off.