Janine Jeffries

Mineral metabolism, bone histomorphometry and vascular calcification in alternate night nocturnal haemodialysis

Background:  Poor control of bone mineral metabolism (BMM) is associated with renal osteodystrophy and mortality in dialysis‐dependent patients. The authors explored the efficacy of alternate nightly home haemodialysis (ANHHD) in controlling BMM parameters and its effects on bone mineral density and histomorphometry.

Changes in serum prolactin, sex hormones and thyroid function with alternate nightly nocturnal home haemodialysis

Aim:  Uraemia is associated with hyperprolactinaemia, low total (TT) and free (FT) serum testosterone, high luteinizing hormone (LH) and follicle‐stimulating hormone (FSH) and, in women, anovulatory cycles and premature menopause. We hypothesize that extended hours haemodialysis may improve these derangements.

Quality of life and alternate nightly nocturnal home hemodialysis

Hemodialysis has been associated with reduced quality of life (QOL). Small cohort studies of quotidian hemodialysis regimens suggest general QOL and dialysis‐related symptoms may improve compared with conventional regimens. An observational cohort study was conducted on 63 patients (age 51.7 ± 12.9 years; 79.4% male; 33.3% diabetes; duration of renal replacement therapy 1.9 [0.7–6.4] years) converted from conventional home hemodialysis (3–5 sessions weekly, 3–6 h/session) to home nocturnal home hemodialysis (NHD) (3–5 sessions weekly, 6–10 h/session). Kidney Disease Quality of Life (KDQOL) and Assessment of Quality of Life instruments and 6‐minute–walk tests were applied at baseline and 6 months. Baseline and 6 month surveys were returned by 70% of patients. On KDQOL, significant improvements in general health (P=0.02) and overall health ratings (P=0.0008), physical function (P=0.003), physical role (P=0.018), and energy and fatigue (P=0.027) were documented. There was a trend toward improvement in burden of kidney disease (P=0.05) and emotional role (P=0.066). There was a significant improvement in distance covered in the 6‐minute–walk test from 513 m (420.5–576.4) to 536.5 m (459–609), P=0.007. On Assessment of Quality of Life, there was a trend toward improvement in overall utility score from 0.65 (0.39–0.81) to 0.73 (0.46–0.86), P=0.096. After 86.2 patient‐years of observation, 23 patients have discontinued NHD (12 transplanted, 5 deceased, 4 psychosocial problems, 1 dialysis access problem, 1 medically unsuitable). Nocturnal home hemodialysis is a sustainable therapy. In addition to improving general QOL, alternate nightly NHD can significantly improve physical functioning as measured by KDQOL and 6‐minute–walk tests.

Complications of home hemodialysis

Home hemodialysis is regaining popularity as a treatment choice for end‐stage kidney disease. This trend is fueled by numerous reports of better survival and improved quality of life with primarily home‐based more frequent and/or longer hours of hemodialysis. Home hemodialysis in the contemporary era is generally very safe. Advances in machine technology have reduced technical complications and longer and more frequent treatments have reduced the risk of hypotension and cardiovascular instability. A successful home hemodialysis program must focus on patient safety to prevent serious hemorrhage from needle dislodgement and enable an aseptic cannulation technique. In addition, vigilance in relation to machine maintenance procedures and attention to water quality are key skills that patients must acquire for optimal outcomes. The possibility of increased septic events with longer and more frequent hemodialysis regimens performed in the home, the long‐term psychosocial effects of home hemodialysis, and the best methods for maintaining compliance of patients in the long term are of particular contemporary interest.

Cardiac and vascular structure and function parameters do not improve with alternate nightly home hemodialysis: An interventional cohort study

BackgroundNightly extended hours hemodialysis may improve left ventricular hypertrophy and function and endothelial function but presents problems of sustainability and increased cost. The effect of alternate nightly home hemodialysis (NHD) on cardiovascular structure and function is not known.MethodsSixty-three patients on standard hemodialysis (SHD: 3.5-6 hours/session, 3-5 sessions weekly) converted to NHD (6-10 hours/session overnight for 3-5 sessions weekly). 2Dimensional transthoracic echocardiography and ultrasound measures of brachial artery reactivity (BAR), carotid intima-media thickness (CIMT), total arterial compliance (TAC) and augmentation index (AIX) were performed post dialysis at baseline and 18-24 months following conversion to NHD. In 37 patients, indices of oxidative stress: plasma malonyldialdehyde (MDA) and anti-oxidant enzymes: catalase (CAT), glutathione peroxidase (GPX) and superoxide dismutase (SOD) activity and total antioxidant status (TAS) were measured at baseline, 3 and 6 months.ResultsLeft ventricular mass index (LVMI) remained stable. Despite significant derangement at baseline, there were no changes in diastolic function measures, CIMT, BAR and TAC. AIX increased. Conversion to NHD improved bone mineral metabolism parameters and blood pressure control. Interdialytic weight gains increased. No definite improvements in measures of oxidative stress were demonstrated.ConclusionsDespite improvement in uremic toxin levels and some cardiovascular risk factors, conversion to an alternate nightly NHD regimen did not improve cardiovascular structure and function. Continuing suboptimal control of uremic toxins and interdialytic weight gains may be a possible explanation. This study adds to the increasing uncertainty about the nature of improvement in cardiovascular parameters with conversion to intensive hemodialysis regimens. Future randomized controlled trials will be important to determine whether increases in dialysis session duration, frequency or both are most beneficial for improving cardiovascular disease whilst minimizing costs and the impact of dialysis on quality of life.