Background Owing to its longer treatment duration—up to 8 hours per dialysis treatment—in-center thrice-weekly nocturnal hemodialysis (HD) is receiving greater attention. To better understand the ...evidence for in-center nocturnal HD, we sought to systematically review the literature to determine the effects of in-center nocturnal HD versus conventional HD on clinically relevant outcomes. Study Design We searched MEDLINE, Embase, Evidence-Based Medicine Reviews (EBMR), Web of Science, and Scopus from the earliest date in the database to November 2016. Setting & Population Adults receiving in-center nocturnal HD compared with those receiving conventional HD. Selection Criteria for Studies All quasi-experimental and observational studies were considered; randomized trials were sought but not found. Predictor Nocturnal vs conventional in-center HD. Outcomes Indexes of blood pressure and left ventricular hypertrophy, markers of anemia, measures of bone mineral metabolism, nutrition, quality of life, sleep quality, episodes of intradialytic hypotension, hospitalization, and mortality. Results Of 2,086 identified citations, 21 met the inclusion criteria, comprising a total of 1,165 in-center nocturnal HD patients and 15,865 conventional HD patients. Although there was substantial heterogeneity in reporting of outcomes, we pooled data for measures of blood pressure, anemia, and mineral metabolism. Though heterogeneity was generally high, in-center nocturnal HD was associated with improved systolic blood pressure (−3.18 95% CI, −5.58 to −0.78) mm Hg, increased hemoglobin levels (0.53 95% CI, 0.11-0.94 g/dL), and lower serum phosphate levels (−0.97 95% CI, −1.48 to −0.46 mg/dL). Limitations No randomized trials have been conducted to address the clinical effects of in-center nocturnal HD. The quality of the observational literature contributing to the results of this review was generally poor to moderate. Confounded outcomes are a significant concern. Publication bias and outcome reporting bias remain possibilities. Conclusions Relative to conventional HD, in-center nocturnal HD was associated with improvements in several clinically relevant outcomes. Other benefits may not have been detected due to small sample sizes of included studies; no prespecified outcome was worse with in-center nocturnal HD.
Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences ...in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.
Background The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks ...and benefits of the buttonhole compared with the rope-ladder technique is uncertain. Study Design A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded). Setting & Population HD patients (both in-center conventional HD and home HD) using an AVF for vascular access. Selection Criteria for Studies We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique. Intervention Buttonhole versus rope-ladder cannulation technique. Outcomes The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality. Results Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, −0.76 95% CI, −1.38 to −0.15 standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 95% CI, −0.76 to 1.43 standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections. Limitations Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes. Conclusions Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.
Background There has been resurgent interest in home hemodialysis (HD) in recent years because of the reported benefits and its excellent safety record. However, the potential for adverse events, ...including potentially catastrophic ones, exists when patients are performing HD in their homes without supervision. There is a lack of literature on this important topic. Study Design Quality improvement report. Setting & Participants We present the experience of 2 adult home HD programs in Canada from 2001 to 2012, including a total of 190 patients and approximately 500 patient-years of treatments. Quality Improvement Plan We retrospectively reviewed all life-threatening adverse events occurring in our programs and re-examined our approach to patient training, retraining, and safety monitoring. Results We report 1 death and 6 potentially fatal adverse events, yielding a crude rate of 0.060 events/1,000 dialysis treatments. Six of 7 events involved significant blood loss (including 1 exsanguination); 5 of 7 events involved human error with lapses in protocol adherence. Because such events are rare, evaluation of specific intervention strategies will require much longer follow-up. Limitations Retrospective identification of cases. A specific quality improvement initiative was not undertaken. Conclusions Life-threatening adverse events in home HD are uncommon; however, when one does occur, this should prompt review of home HD–related policies and procedures to make this therapy even safer.
Background Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis. Study Design We conducted a systematic review to inform ...clinical practice guidelines for the provision of intensive hemodialysis. Setting & Population Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent ≥5 hemodialysis treatments per week and/or long >5.5 hours per hemodialysis treatment). Selection Criteria for Studies We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011). Interventions (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users. Outcomes Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life. Results We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices. Limitations Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors. Conclusions This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.
Background Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has ...been associated with improvement in hyperphosphatemia that may improve outcomes. Study Design Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. Setting & Population Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. Selection Criteria for Studies We included clinical trials, cohort studies, case series, case reports, and systematic reviews. Interventions Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. Outcomes Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. Results 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. Limitations Almost all the available information is related to changes in laboratory values and surrogate outcomes. Conclusions Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
...the patient initially presented with a sign wave pattern on the ECG which can rapidly progress to ventricular fibrillation 3. ...the serum potassium was greater than 6 mEq/L for 7.5 hours (and >10 ...mEq/L for 2 hours) thus placing the patient at high risk for arrhythmia.
Abstract Background Home hemodialysis is associated with lower costs to the health care system compared with conventional facility-based hemodialysis because of lower staffing and overhead costs, and ...by transferring the treatment cost of utilities (water and power) to the patient. The purpose of this study was to determine the utility costs of home hemodialysis and create a formula such that patients and renal programs can estimate the annual patient-borne costs involved with this type of treatment. Methods Seven common combinations of treatment duration and dialysate flows were replicated 5 times using various combinations of home hemodialysis and reverse osmosis machines. Real-time utility (electricity and water) consumption was monitored during these simulations. A generic formula was developed to allow patients and programs to calculate a more precise estimate of utility costs based on individual combinations of dialysis intensity, frequency and utility costs unique to any patient. Results Using typical 2014 utility costs for Edmonton, the most expensive prescription was for nocturnal home hemodialysis (8 h at 300 mL/min, 6 d/wk), which resulted in a utility cost of $1269 per year; the least expensive prescription was for conventional home hemodialysis (4 h at 500 mL/min, 3 d/wk), which cost $420 per year. Water consumption makes up most of this expense, with electricity accounting for only 12% of the cost. Interpretation We show that a substantial cost burden is transferred to the patient on home hemodialysis, which would otherwise be borne by the renal program.
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