Original investigation: dialysis therapy
Long-term study of high-comorbidity ESRD patients converted from conventional to short daily hemodialysis

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Abstract

Background: Conventional hemodialysis (CHD) is associated with suboptimal clinical outcomes and high mortality rates. Daily hemodialysis (DHD) has been reported to improve outcomes and quality of life (QOL), predominantly in self-care or home dialysis populations. The effect of short DHD (sDHD) on patients with end-stage renal disease (ESRD) with high comorbidities has not been established. Methods: This prospective study compared clinical outcomes and QOL in high-comorbidity patients with ESRD converted from CHD to sDHD while maintaining the same total weekly dialysis time. Study patients had 4.0 ± 1.7 major comorbid conditions in addition to ESRD. Standard dialysis parameters, antihypertensive and erythropoietin (EPO) requirements, Kidney Disease Quality of Life (KDQOL) measurements, vascular access problems, and hospitalization rates were compared while on sDHD therapy versus the previous 12 months on CHD therapy. Results: Forty-two patients were studied on sDHD therapy for 793 patient-months during a 72-month period. During sDHD, standard Kt/V increased 31%, hospitalization days decreased significantly by 34%, and vascular access problems did not increase. Cumulative survival was 33% at 6 years. In the 20 patients who remained on sDHD therapy for 12 months, after 1 year, we found significant improvements in KDQOL scores, a 69% reduction in antihypertensive medications with stable blood pressure, and a 45% reduction in EPO requirements with stable hematocrits. We hypothesize that these improvements are the result of the less extreme solute and fluid fluctuations and greater dialysis dose provided by sDHD, even when weekly dialysis time is unchanged. Conclusion: High-comorbidity patients with ESRD converted to sDHD therapy had significantly improved clinical outcomes and QOL and decreased hospitalizations, with no increase in vascular access problems.

Section snippets

Patient selection

Inclusion criteria were age older than 18 years, 3- or 4-times-weekly hemodialysis or peritoneal dialysis for at least 3 months, adequate vascular access, compliance with fluid management and treatment protocols, ability to understand and sign informed consent, and, for in-center patients, willingness to reuse dialyzers and ability to transport to and from the clinic 6 times a week. Initially, patient selection was based on medical indications to justify the additional expenses; nonmedical

Patients

We enrolled 42 patients (28 men, 14 women; mean age, 59.9 ± 16.7 years) between October 14, 1996, and October 13, 2002. Study patients were enrolled from approximately 550 hemodialysis patients. Thirty-seven of 42 patients had been on dialysis therapy for at least 12 months before starting sDHD. All patients had been on hemodialysis therapy at least 3 months before starting sDHD therapy, except for 2 patients who converted from peritoneal dialysis therapy (32 and 34 months on peritoneal

Discussion

Our study differs from almost every other DHD report in that we used a negative patient selection bias. Most of our patients were failing on CHD therapy and enrolled in this study as a form of “rescue therapy.” Our findings show that the improved clinical outcomes and QOL reported by others apply also to this high-comorbidity ESRD population.

We enrolled twice as many men as women, an interesting finding reported by virtually every other DHD investigator.14, 17, 18, 19, 20 The reason for this

Acknowledgements

The authors thank Dr Frank Gotch for invaluable assistance with calculations of eKt/V and stdKt/V for this manuscript and El Camino Hospital, a nonprofit district hospital, for its support and willingness to absorb the economic impact of providing this therapy to the most vulnerable patients with ESRD in its community.

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    Supported in full by El Camino Hospital, Mountain View, CA.

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    Copyright © 2003 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.