Daily nocturnal home hemodialysis
2004; Elsevier BV; Volume: 65; Issue: 5 Linguagem: Inglês
10.1111/j.1523-1755.2004.00603.x
ISSN1523-1755
Autores Tópico(s)Renal and Vascular Pathologies
ResumoA 49-year-old man developed end-stage renal disease (ESRD) secondary to polycystic kidney disease. He had undergone home hemodialysis for the past 8 years, with dialysis 3 times weekly for 5 hours per session via an arteriovenous (AV) fistula. He received a cadaveric kidney 5 years ago. Delayed graft function was complicated by cytomegalovirus infection and severe cardiomyopathy, which had not been recognized when he received the transplant. An echocardiogram after transplantation revealed poor function of his left ventricle (ejection fraction 160/95 mm Hg). She complained of headaches and could not tolerate a decrease in her dry weight. She was trained in DNHD 2 years ago. After the conversion, her dry weight was decreased progressively from 53 to 49 kg within 1 month despite the previous lack of evidence of increased ECF volume. Her blood pressure control improved but she continued to need most of the antihypertensives. Despite resistance she was convinced to accept a decrease in her dry weight further to 47 kg. Her blood pressure normalized and all medications were discontinued but only 2 to 5 months after completion of her training. As a result of improving appetite, however, her dry weight was increased progressively from 47.0 to 50.5 kg over 6 months. The ECF volume, measured using single-frequency BIA, decreased from 14.3 kg prior to the conversion to DHND to 12.4 kg one month later, and further to 10.2 kg 8 months after the conversion while her dry weight was increasing. The ECF/ICF ratio measured by BIA decreased similarly from 0.97 to 0.80 and 0.66 before, 1, and 8 months after the conversion. Her hemoglobin, 10.5 g/dL at the time of the conversion, increased to 14.1 g/dL after the initial decrease in the dry weight and remained stable over the following 2 years at 13.4 ± 1.2 g/dL. The dose of Epo of 6000 U/week subcutaneously at the time of the training was gradually discontinued 8 months after the conversion. She has not taken Epo for 13 months. Dr. Andreas Pierratos (Head, Home Dialysis Unit, Humber River Regional Hospital, and Associate Professor of Medicine, University of Toronto, Toronto, Canada): Daily nocturnal home hemodialysis (DNHD) combines the advantages of home hemodialysis, short daily hemodialysis (SDHD) and long intermittent hemodialysis. Daily nocturnal home hemodialysis was started in Toronto in 1994 by Dr. Robert Uldall with the help of a grant from the Ministry of Health, province of Ontario, Canada [abstract; Uldall PR et al, J Am Soc Nephrol 5:428, 1994]. It is done at home by the patient or a family member at night during sleep for an average of 8 hours usually 6 nights a week [1.Pierratos A. Ouwendyk M. Francoeur R. et al.Nocturnal hemodialysis: Three-year experience.J Am Soc Nephrol. 1998; 9: 859-868PubMed Google Scholar]. I first will review briefly the history and some data on home, long intermittent, and short daily hemodialysis before discussing daily nocturnal hemodialysis, a new and provocative topic in the dialysis world. Home hemodialysis was first used by Nosé in Japan in 1963 [2.Blagg C.R. A brief history of home hemodialysis.Adv Ren Replace Ther. 1996; 3: 99-105PubMed Google Scholar]. Home hemodialysis utilization, high in the 1970s, has since declined significantly worldwide. Some of the reasons include the introduction of continuous ambulatory peritoneal dialysis (CAPD), an increase in the number of dialysis units in developed countries, financial constraints, and the increasing number of patients with significant co-morbidities who are unable to perform their own dialysis [2.Blagg C.R. A brief history of home hemodialysis.Adv Ren Replace Ther. 1996; 3: 99-105PubMed Google Scholar]. Although some of the superior results of home hemodialysis might be related to the selection of stable patients, a retrospective analysis of United States Renal Data System (USRDS) data suggested a decreased mortality risk ratio for home hemodialysis patients after adjustment for age, gender, race, and co-morbidities (RR 0.58, P = 0.03) [3.Woods J.D. Port F.K. Stannard D. et al.Comparison of mortality with home hemodialysis and center hemodialysis: a national study.Kidney Int. 1996; 49: 1464-1470Abstract Full Text PDF PubMed Scopus (136) Google Scholar]. Better quality of life, independence, and vocational rehabilitation have been some of the benefits of home hemodialysis [4.Oberley E.T. Schatell D.R. Home hemodialysis: survival, quality of life, and rehabilitation.Adv Ren Replace Ther. 1996; 3: 147-153PubMed Google Scholar]. The decline in utilization of CAPD, overcrowding of dialysis units, shortage of nurses, and lower cost of home hemodialysis have rekindled the interest in home hemodialysis. The use of long, usually 8 hours, dialysis was necessary during the early years because inefficient dialyzers were used. The Dialysis Unit in Tassin, France is the best known unit that has continued using the 8-hour, thrice-weekly schedule, now for more than 30 years [5.Laurent G. Charra B. The results of an 8 h thrice weekly haemodialysis schedule.Nephrol Dial Transplant. 1998; 13: 125-131Crossref PubMed Scopus (74) Google Scholar]. Patient survival has been high, 75% over 10 years. Although the early patient cohorts had fewer comorbidities, the survival rate of the later cohorts (54% over 5 years) was still twice as high as those reported by USRDS. Blood pressure control has been excellent even without the use of antihypertensive medications, as a result of a progressive decrease in the postdialysis weight (dry weight) and low-salt diet. Interestingly, despite good blood pressure control, lack of regression of left-ventricular hypertrophy (LVH) has been reported [6.McGregor D.O. Buttimore A.L. Nicholls M.G. Lynn K.L. Ambulatory blood pressure monitoring in patients receiving long, slow home haemodialysis.Nephrol Dial Transplant. 1999; 14: 2676-2679Crossref PubMed Scopus (49) Google Scholar]. Also, despite increased middle molecule clearance by long hemodialysis [7.Clark W.R. Leypoldt J.K. Henderson L.W. et al.Quantifying the effect of changes in the hemodialysis prescription on effective solute removal with a mathematical model.J Am Soc Nephrol. 1999; 10: 601-609PubMed Google Scholar], dialysis-related amyloidosis has not been avoided [8.Laurent G. Calemard E. Charra B. Dialysis related amyloidosis.Kidney Int. 1988; 24: S32-S34Google Scholar]. The lack of use of modern technology and Epo might be relevant. Phosphate control is improved on long intermittent hemodialysis, but phosphate binders are needed for the majority of the patients. Resurgence of the popularity of long intermittent hemodialysis thrice weekly or every other day, in-center or at home at night, has recently provided a cost-effective way of improving dialysis efficacy within the limits of current reimbursement rates [abstract; Kurella M et al, J Am Soc Nephrol 13:410A, 2002]. Short daily hemodialysis was first described by DePalma in 1969 [9.DePalma J.R. Pecker E.A. Maxwell M.H. A new automatic coil dialyser system for “daily” dialysis.Proc EDTA. 1969; 6: 26-34Google Scholar]. Despite patient improvement, early successful efforts were abandoned because of the financial burden [10.Kjellstrand C.M. Ing T. Daily hemodialysis: history and revival of a superior dialysis method.ASAIO J. 1998; 44: 117-122Crossref PubMed Scopus (49) Google Scholar]. Most of the literature on SDHD has originated in Italy over the last 15 years [11.Bonomini V. Mioli V. Albertazzi A. Scolari P. Daily-dialysis programme: Indications and results.Nephrol Dial Transplant. 1998; 13: 2774-2777Crossref PubMed Scopus (34) Google Scholar, 12.Buoncristiani U. Quintaliani G. Cozzari M. et al.Daily dialysis: Long-term clinical metabolic results.Kidney Int. 1988; 24: S137-S140Google Scholar], mainly from Buoncristiani's group. A recent resurgence of interest led to publications by several groups in Europe as well as North and South America [13.Kooistra M.P. Vos J. Koomans H.A. Vos P.F. Daily home haemodialysis in The Netherlands: Effects on metabolic control, haemodynamics, and quality of life.Nephrol Dial Transplant. 1998; 13: 2853-2860Crossref PubMed Scopus (203) Google Scholar, 14.Ting G. Future role of short daily hemodialysis, an opinion based on a California study.Semin Dial. 1999; 12: 448-450Crossref Scopus (15) Google Scholar, 15.Woods J.D. Port F.K. Orzol S. et al.Clinical and biochemical correlates of starting “daily” hemodialysis.Kidney Int. 1999; 55: 2467-2476Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar, 16.Traeger J. Sibai-Galland R. Delawari E. Arkouche W. Daily versus standard hemodialysis: One year experience.Artif Organs. 1998; 22: 558-563Crossref PubMed Scopus (63) Google Scholar, 17.Andre M.B. Rembold S.M. Pereira C.M. Lugon J.R. Prospective evaluation of an in-center daily hemodialysis program: Results of two years of treatment.Am J Nephrol. 2002; 22: 473-479Crossref PubMed Scopus (32) Google Scholar]. Despite some variations, the dialysis regimen comprises 2.0 to 2.5 hours of high-efficiency dialysis 6 days per week, either in center or at home. The rationale of SDHD is that it provides enhanced hemodynamic stability and increases solute removal by delivering dialysis when the plasma-to-dialysate gradient is highest. Urea standard Kt/V (stdKt/V), a new yardstick of dialysis dose proposed by Gotch in 1998 [18.Gotch F.A. The current place of urea kinetic modelling with respect to different dialysis modalities.Nephrol Dial Transplant. 1998; 13: 10-14Crossref PubMed Scopus (264) Google Scholar], is used to compare the dose offered by dissimilar dialysis regimens. The stdKt/V is the same for all dialysis methods characterized by the same midweek predialysis blood urea nitrogen (BUN). Conventional hemodialysis (CHD) and CAPD, with a weekly stdKt/V of 2 (as per DOQI guidelines), have the same outcomes, so it is assumed that this observation applies to other modalities with similar stdKt/V. This conclusion needs to be experimentally confirmed, however. An SDHD of similar length per week with CHD offers a higher stdKt/V of about 3.5 and therefore can potentially explain better outcomes [19.Galland R. Traeger J. Delawari E. et al.Daily hemodialysis versus standard hemodialysis: Urea TAC, TAD, weekly eKt/v, Std(Kt/v) and nPCR.Home Hemodial Int. 1999; 3: 33-36Crossref Google Scholar]. Larger molecule removal is also enhanced by daily hemodialysis [7.Clark W.R. Leypoldt J.K. Henderson L.W. et al.Quantifying the effect of changes in the hemodialysis prescription on effective solute removal with a mathematical model.J Am Soc Nephrol. 1999; 10: 601-609PubMed Google Scholar, 20.Pierratos A. Effect of therapy time and frequency on effective solute removal.Semin Dial. 2001; 14: 284-288Crossref PubMed Google Scholar, 21.Fagugli R.M. De Smet R. Buoncristiani U. et al.Behavior of non-protein-bound and protein-bound uremic solutes during daily hemodialysis.Am J Kidney Dis. 2002; 40: 339-347Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 22.Floridi A. Antolini F. Galli F. et al.Daily haemodialysis improves indices of protein glycation.Nephrol Dial Transplant. 2002; 17: 871-878Crossref PubMed Scopus (47) Google Scholar]. Short daily hemofiltration, introduced recently, increases the large molecule removal further, despite a lower removal rate of smaller molecules [23.Leypoldt J.K. Jaber B.L. Lysaght M.J. et al.Kinetics and dosing predictions for daily haemofiltration.Nephrol Dial Transplant. 2003; 18: 769-776Crossref PubMed Scopus (47) Google Scholar]. Several studies have shown significant improvement of quality of life after conversion to SDHD [13.Kooistra M.P. Vos J. Koomans H.A. Vos P.F. Daily home haemodialysis in The Netherlands: Effects on metabolic control, haemodynamics, and quality of life.Nephrol Dial Transplant. 1998; 13: 2853-2860Crossref PubMed Scopus (203) Google Scholar, 24.Mohr P.E. Neumann P.J. Franco S.J. et al.The case for daily dialysis: its impact on costs and quality of life.Am J Kidney Dis. 2001; 37: 777-789Abstract Full Text PDF PubMed Scopus (126) Google Scholar]. Blood pressure control improves, and the dose of antihypertensive agents can be decreased by more than 50% [15.Woods J.D. Port F.K. Orzol S. et al.Clinical and biochemical correlates of starting “daily” hemodialysis.Kidney Int. 1999; 55: 2467-2476Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar]. Also SDHD leads to regression of LVH [25.Fagugli R.M. Reboldi G. Quintaliani G. et al.Short daily hemodialysis: Blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients.Am J Kidney Dis. 2001; 38: 371-376Abstract Full Text PDF PubMed Scopus (224) Google Scholar]. Both blood pressure control as well as regression of LVH have been associated with a decrease in the ECF volume [25.Fagugli R.M. Reboldi G. Quintaliani G. et al.Short daily hemodialysis: Blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients.Am J Kidney Dis. 2001; 38: 371-376Abstract Full Text PDF PubMed Scopus (224) Google Scholar][abstract; Nesrallah G et al, J Am Soc Nephrol 12:273A, 2001]. SDHD increases phosphate removal but improving appetite and increased phosphate intake help maintain the serum phosphate level [abstract; Traeger J et al, J Am Soc Nephrol 13:410A–411A, 2002]; the dose of phosphate binders does not change consistently [13.Kooistra M.P. Vos J. Koomans H.A. Vos P.F. Daily home haemodialysis in The Netherlands: Effects on metabolic control, haemodynamics, and quality of life.Nephrol Dial Transplant. 1998; 13: 2853-2860Crossref PubMed Scopus (203) Google Scholar]. Nutritional parameters improve on SDHD, including serum albumin, pre-albumin, protein intake, and body weight, although not all studies have reported these findings [26.Galland R. Traeger J. Arkouche W. et al.Short daily hemodialysis rapidly improves nutritional status in hemodialysis patients.Kidney Int. 2001; 60: 1555-1560Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar]. Hematocrit improved in most studies despite a decrease in the dose of Epo by as much as 40%; some studies did not confirm this observation, probably because of iron deficiency or inadequate length of follow-up [15.Woods J.D. Port F.K. Orzol S. et al.Clinical and biochemical correlates of starting “daily” hemodialysis.Kidney Int. 1999; 55: 2467-2476Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar, 27.Klarenbach S. Heidenheim A.P. Leitch R. Lindsay R.M. Reduced requirement for erythropoietin with quotidian hemodialysis therapy.ASAIO J. 2002; 48: 57-61Crossref PubMed Scopus (32) Google Scholar]. Let me now turn to my major theme, that is, that daily nocturnal hemodialyis is the best form of chronic hemodialysis. Quality-of-life instruments showed significant improvement in the quality of life, including the sickness impact profile, Beck Depression Index, and 3 parameters of SF-36 [24.Mohr P.E. Neumann P.J. Franco S.J. et al.The case for daily dialysis: its impact on costs and quality of life.Am J Kidney Dis. 2001; 37: 777-789Abstract Full Text PDF PubMed Scopus (126) Google Scholar][abstract; Brissenden JE et al, J Am Soc Nephrol 9:168A, 1998]. Uremic and dialysis-related symptoms disappear, usually within the first month, but full recovery is not complete for almost 1 year. The level of energy improves and leads to social and vocational rehabilitation. Patient or family member training is performed while the patient is undergoing CHD. Training lasts for 2 to 8 weeks, usually 5 weeks, followed by 3 dialysis sessions overnight in the training center. The remarkable stability offered by DNHD allows patients with hemodynamic instability on CHD to be dialyzed at home. Excluding patients who cannot receive heparin, no medical contraindication to this modality has been encountered. I should stress this point since traditionally only healthier patients were selected for home hemodialysis. Patients with severe congestive heart failure, systemic hypotension, coronary artery disease, ascites, hemodynamic instability, or systemic hypotension benefit significantly from DNHD. Over 9 years, 90 patients were trained at the Humber River Regional Hospital in Toronto. These patients were aged 49 ± 11 years; 57 were males, 33 females. Of the 88, 9 died, 10 left the program, 16 had renal transplantation, 48 currently dialyze every night, and 5 dialyze every other night because they are awaiting further funding so that they can be converted to the every night treatment. The average time in the program was 30 ± 27 months, and the total experience is 230 patient-years. The longest period in the program is 9 years. Approximately 90 patients use DNHD in Toronto. Daily nocturnal home hemodialysis can be done using conventional hemodialysis machines. Blood and dialysate flows vary, with an average blood flow of 250 mL/min and a dialysate flow of 300 mL/min. Dialysate flows as low as 100 mL/min or higher than 500 mL/min have been used [1.Pierratos A. Ouwendyk M. Francoeur R. et al.Nocturnal hemodialysis: Three-year experience.J Am Soc Nephrol. 1998; 9: 859-868PubMed Google Scholar]. No sodium ramping or ultrafiltration profiling is necessary. The presence of a dialysis partner is not required. When compared to CHD, the dialysate composition of DNHD contains a lower bicarbonate level (average 32 mEq/L), a higher calcium level (average 3.2 mEq/L, 1.6 mmol/L), and might include sodium phosphate (see later). Use of ultrapure dialysate is desirable, but the current data have been collected by using water compliant with the Association for the Advancement of Medical Instrumentation (AAMI) guidelines [28.Francoeur R. Digiambatista A. Technical considerations for short daily home hemodialysis and nocturnal home hemodialysis.Adv Ren Replace Ther. 2001; 8: 268-272Abstract Full Text PDF PubMed Scopus (12) Google Scholar]. Heparin use is similar to that for conventional hemodialysis. Central venous catheters, fistulas, and grafts have been used as accesses. Safety devices preventing air embolism or disconnection of the catheters are mandatory [1.Pierratos A. Ouwendyk M. Francoeur R. et al.Nocturnal hemodialysis: Three-year experience.J Am Soc Nephrol. 1998; 9: 859-868PubMed Google Scholar]. Moisture sensors taped onto the needle sites provide warning in cases of bleeding or needle dislodgement. A “single-needle system” provides adequate blood flow (200 mL/min) and requires the same number of cannulations per week as does conventional hemodialysis. It represents the preferred and safest configuration. The use of the same puncture hole (buttonhole) technique in fistulas is optional but provides easier, more predictable, and less painful cannulation [29.Twardowski Z. Kubara H. Different sites versus constant sites of needle insertion into arteriovenous fistulas for treatment by repeated dialysis.Dial Transplant. 1979; 8: 978-980Google Scholar]. “Live” remote monitoring during dialysis using a telephone or internet connection can provide extra safety and psychologic support and can help with patient compliance, but at this point it is not considered mandatory [30.Pierratos A. Nocturnal home haemodialysis: an update on a 5-year experience.Nephrol Dial Transplant. 1999; 14: 2835-2840Crossref PubMed Scopus (196) Google Scholar, 31.Hoy C.D. Remote monitoring of daily nocturnal hemodialysis.Hemodialysis Int. 2001; 4: 8-12Google Scholar]. The internet has allowed cost-efficient use of remote monitoring. It is expected that improvement in technology with inclusion of biologic monitoring (blood pressure, heart rate, oximetry, etc.) will increase the value of “live” remote monitoring. Refrigeration of dialyzers at the home of the patient, and their delivery to the dialysis center only once weekly, allows successful dialyzer reprocessing, if desired [32.Pierratos A. Francoeur R. Ouwendyk M. Delayed dialyzer reprocessing for home hemodialysis.Home Hemodial Int. 2000; 4: 51-54Google Scholar]. The dialysis dose on DNHD is high. The Kt/V calculated using dialysate collection was 0.99 ± 0.3 using a dialysate flow of 100 mL/min [1.Pierratos A. Ouwendyk M. Francoeur R. et al.Nocturnal hemodialysis: Three-year experience.J Am Soc Nephrol. 1998; 9: 859-868PubMed Google Scholar]. Using higher dialysate flow, single-pool Kt/V (spKt/V) usually yields a Kt/V of about 2 [33.Chan C.T. Floras J.S. Miller J.A. et al.Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis.Kidney Int. 2002; 61: 2235-2239Abstract Full Text Full Text PDF PubMed Scopus (327) Google Scholar]. The weekly standard Kt/V as defined by Gotch is about 5 [34.Gotch F.A. Is Kt/V urea a satisfactory measure for dosing the newer dialysis regimens?.Semin Dial. 2001; 14: 15-17Crossref PubMed Google Scholar]. Therefore DNHD is particularly well-suited for large patients. Due to the long total duration of dialysis, larger molecule removal is high. This was shown by simulated computer models [7.Clark W.R. Leypoldt J.K. Henderson L.W. et al.Quantifying the effect of changes in the hemodialysis prescription on effective solute removal with a mathematical model.J Am Soc Nephrol. 1999; 10: 601-609PubMed Google Scholar, 35.Goldfarb-Rumyantzev A.S. Cheung A.K. Leypoldt J.K. Computer simulation of small-solute and middle-molecule removal during short daily and long thrice-weekly hemodialysis.Am J Kidney Dis. 2002; 40: 1211-1218Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar] and by measuring weekly dialysate β2-microglobulin removal. The amount of β2-microglobulin removed increased fourfold after conversion from CHD to DNHD (127 ± 48 mg versus 585 ± 309 mg, P < 0.001). Serum β2-microglobulin levels decreased over time from 27.2 ± 11.7 mg/dL at initiation of DNHD, to 13.7 ± 4.4 mg/dL by 9 months [36.Raj D.S. Ouwendyk M. Francoeur R. Pierratos A. Beta(2)-microglobulin kinetics in nocturnal haemodialysis.Nephrol Dial Transplant. 2000; 15: 58-64Crossref PubMed Scopus (139) Google Scholar]. It is possible that the decrease in β2-microglobulin production is partially responsible, as there is variability in the serum levels while on the same regimen. To this point, no evidence of “deficiency syndromes” caused by excessive dialysis has surfaced. Phosphate removal by conventional hemodialysis is suboptimal, and an elevated calcium x phosphorus product is associated with increased patient mortality rates [37.Block G.A. Hulbert-Shearon T.E. Levin N.W. Port F.K. Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic hemodialysis patients: a national study.Am J Kidney Dis. 1998; 31: 607-617Abstract Full Text Full Text PDF PubMed Scopus (2013) Google Scholar]. Length of dialysis is a major determinant of phosphate removal. Weekly phosphate removal by DNHD is twice that of CHD (4.8 ± 1.7 g versus 2.2 ± 0.6 g) [38.Mucsi I. Hercz G. Uldall R. et al.Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis.Kidney Int. 1998; 53: 1399-1404Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar]. All patients stop taking phosphate binders within 1 week of the initiation of the treatment and are on an unrestricted phosphate diet. In fact, more than 50% of patients require the addition of sodium phosphate into the dialysate. This is usually achieved by the patient adding sodium phosphate into either the “acid”- (low pH prevents precipitation with calcium) or bicarbonate-containing concentrate. We use Fleet® enema as a source of sodium phosphate. Serum phosphate was normal pre- and postdialysis at 3.6 ± 0.6 mg/dL (1.2 ± 0.21 mmol/L) and 2.6 ± 0.3 mg/dL (0.8 ± 0.1 mmol/L), respectively [abstract; Pierratos A et al, J Am S
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