NEPHROLOGY

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Daily Hemodialysis Helps Protect Kidney Patients’ Hearts

When there is a loss of about 90% of usual kidney function, either kidney transplantation or dialysis is required. Nearly 400,000 people in the United States and 2 million worldwide are dependent on dialysis. Despite improvements in dialysis technology, new medications and more than 40 years of experience, mortality rates remain high at 18 to 20% a year. Patients experience frequent hospitalizations and reduced health-related quality of life.

Results published online in the New England Journal of Medicine (20 November 2010) showed that frequent hemodialysis improved left ventricular mass (heart size) and self-reported physical health compared to conventional hemodialysis for kidney failure. The trial, called the Frequent Hemodialysis Network (FHN) Daily Trial, was funded by the National Institutes of Health and the Centers for Medicare & Medicaid Services.

The study showed that six hemodialysis treatments per week improved left ventricular mass and physical health compared to conventional, three weekly dialysis therapy sessions. Frequent hemodialysis was also associated with improved control of high blood pressure and excessive phosphate levels in the blood, a common problem in patients on hemodialysis. There were no significant effects on cognitive performance, self-reported depression, or the use of drugs to treat anemia.

Previous observational data suggested that the dose of hemodialysis correlates directly with patient survival. However, results from the HEMO Study published in 2002, showed no added benefit of increasing the per-treatment dose of hemodialysis in the conventional three times per week method. However, since that time a few small, single-center studies found that the dialysis dose could be greatly increased by adding more dialysis sessions. Those findings led FHN researchers to test the hypothesis that almost daily treatment would improve both objective and subjective, or patient-reported, outcomes.

The FHN Daily Trial involved 245 patients at 10 university and 54 community-based hemodialysis facilities in North America between Jan. 2006 and March 2010. Patients were randomly assigned to receive either conventional three weekly dialysis treatments or six treatments a week.

Patients in the frequent-hemodialysis group averaged 5.2 sessions per week; the weekly standard Kt/Vurea (the product of the urea clearance and the duration of the dialysis session normalized to the volume of distribution of urea) was significantly higher in the frequent-hemodialysis group than in the conventional-hemodialysis group (3.54+0.56 vs. 2.49+0.27). Frequent hemodialysis was associated with significant benefits with respect to both coprimary composite outcomes (hazard ratio for death or increase in left ventricular mass, 0.61; hazard ratio for death or a decrease in the physical-health composite score, 0.70). Patients randomly assigned to frequent hemodialysis were more likely to undergo interventions related to vascular access than were patients assigned to conventional hemodialysis (hazard ratio, 1.71). Frequent hemodialysis was associated with improved control of hypertension and hyperphosphatemia. There were no significant effects of frequent hemodialysis on cognitive performance, self-reported depression, serum albumin concentration, or use of erythropoiesis-stimulating agents.

According to the authors, frequent hemodialysis, as compared with conventional hemodialysis, was associated with favorable results with respect to the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score but prompted more frequent interventions related to vascular access.

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