LONG DIALYSIS SESSIONS (DAILY, NOCTURNAL ETC) Ercan Ok, Izm ir, Turkey Chair: Mustafa Arici, Ankara, Turkey Bernard Canaud, Montpellier, France Prof Ercan Ok Divis ion of N ephrology E ge U nivers ity Sc hool of M edic ine Izmir, T urkey Slide 1 Dear chairm an, dear colleagues. Slide 2
I would like to start with the history of chronic dialysis. In the early years of chronic dialysis, hem odialysis was perform ed for 20-40 hours per week and results were perfect: excellent blood pressure control, rare intradialytic blood pressure drop, satisfactory nutritional status, sufficient RBC production and nearly full rehabilitation. But later short dialysis was also started. Slide 3 This is one of the first reports, they reduced weekly dialysis tim es from 27 hours to 12 hours and they reported successful adaptation, even an increase in haem oglobin level, sim ilar biochem ical results except phosphate. Then som e questions. Why dialysis m ore than 6 hours a week? Need for a scale? And Kt/V? The National corrective dialysis study says Kt/V above 0.95 is im portant for m orbidity and m ortality rather than the duration of dialysis. Slide 4
But now we face several problem s. We have high m orbidity, num erous problem s, relatively low quality of life, and unacceptably high m ortality rate. For exam ple, life expectancy for a person of 49 years old is 33 years in the general population but only 7 years in dialysis. Slide 5 Several m edications have been studied to im prove outcom es in hem odialysis patients but none of them was prom ising. What about m ore dialysis? What does it m ean? Slide 6
More efficient HD sessions, it has been tried in the HEMO study and they did not find survival benefits with an increase of Kt>/V. What are the other options? More frequent HD sessions, in-centre or at hom e, longer HD sessions in-centre and at hom e and com bination of m ore frequent and longer HD sessions. Slide 7 This is a random ised controlled trial; they com pared in-centre-hd six tim es versus three tim es per week. Prim ary outcom es were death or change in left vascular m ass and death or change in physical-health com posite score. Results dem onstrated that frequent HD is associated with favourable outcom es. Slide 8
Frequent HD provides better blood pressure control, decrease in left vascular m ass, im provem ent of physical-health com posite score, a decrease in pre-dialysis phosphorous level but m ore vascular access interventions. Slide 9 This is another study, a m atched cohort study. Short daily HD was com pared with conventional in-centre HD. This was survival analysis and the results show that there is a m odest im provem ent in survival with short daily hom e HD. This is just a 13% decrease in m ortality risk. Slide 10
So in sum m ary, with m ore frequent hem odialysis, better blood pressure control, progression of left vascular hypertrophy, better quality of life, m odestly better survival but m ore vascular access problem s and probably higher costs. Slide 11 What about longer dialysis? What about duration of HD sessions and m ortality? Both DOPPS data and Japanese Registry clearly indicate that shorter dialysis sessions are associated with increased risk of m ortality. If you decrease duration of dialysis from 4 hours to 2.5 hours, m ortality risk increases to 19% according to DOPPS data and 68% according to Japanese Registry data. Slide 12
In this slide you see the duration of dialysis session in US, Europe, Japan, and TASSIN. These are m ortality data, as you know in both diabetics and non-diabetics. In three tim es weekly HD best survival is obtained with 8 hour sessions. Slide 13 In this slide you see the increase in solute clearance with extension of HD session duration from 4 hours to 8 hours. There was a significant increase in solute clearances especially beta-2 m icroglobulin and phosphate clearance. Slide 14
This is a prospective case controlled study from our group. We evaluated the effect of 4 hour and 8 hour dialysis sessions in-centre HD on several param eters. Here you see hospitalization rate in nocturnal HD and in conventional HD. There was 73% less all-cause hospitalization rate in the nocturnal HD arm com pared to the conventional HD arm. With nocturnal HD there was a 68% decrease in the frequency of intradialytic hypotension episodes and there was no change in the conventional hem odialysis arm. Slide 15 This is phosphate control data. Phosphate level decreased in the nocturnal HD arm along with a decrease in proportion of patients requiring phosphate binders, it decreased from 83% to 22%. Slide 16
Hem oglobulin levels rem ained stable in the nocturnal HD arm and conventional HD arm but the proportion of patients requiring EPO decreased from 55% to 24%. Slide 17 Here you see body weight change and serum album in change in the nocturnal HD arm and in the conventional HD arm. As you see, pink bars show nocturnal HD, there was an increase in body weight and also serum album in level with a 1 year follow-up. Slide 18
Blood pressure rem ained stable in both groups but a proportion of patients on antihypertensive m edication decreased from 24% to 8% in the nocturnal HD group. Slide 19 These are echocardiographic data. We were able to show regression of left atrial diam eter and also of left vascular m ass index in the nocturnal HD group and there was no change in the conventional HD group. Slide 20
This is a m eta-analysis to assess the effect of intensive HD on blood pressure and results show a m ean reduction of 15 m m Hg in systolic blood pressure and a decrease in requirem ents for hypertensive m edication. Slide 21 The sam e study also evaluated effect of intensive HD on left vascular m ass index and m ost of the studies intensive HD regarding left vascular m ass index and the m ean value was regression of left vascular m ass index by 31 g/m 2 of better surface area. Slide 22
In a subgroup of our nocturnal HD trial we evaluated arterial stiffness in the nocturnal HD arm and in the conventional HD arm and we found that nocturnal HD is associated with a decrease in pulse wave velocity. Augm entation index decreased in the nocturnal HD group and increased in the conventional HD group. Serum phosphate level was predictive for change in both pathway velocity and augm entation index. Slide 23 We also perform ed m ulti-slice CT in order to m easure coronary artery calcification score at the beginning and at the end of the study. We found that lower progression rate with nocturnal HD in patients with m oderate to severe vascular calcification at baseline. Again, serum phosphate level was predictive for coronary artery calcification progression. Slide 24
In this slide you see the clinical benefits of intensive HD. Nocturnal HD provides beneficial effect in term s of blood pressure control, left vascular hypertrophy, left vascular systolic function, arterial com pliance, sleep apnoea, cardiac autonom ic abnorm alities, excellent phosphate control, anaem ia, inflam m ation cognitive function and in fertility. Slide 25 What about m ore frequent and longer hem odialysis at hom e? In this random ised controlled trial they evaluated progression of LVM m easured by MRI within a 6 m onths study period. They found successful blood pressure control with nocturnal hom e HD, excellent phosphate control and significant decrease in left vascular m ass with nocturnal hom e HD. Slide 26
Here s survival data about nocturnal hom e HD. In this m atched cohort study 338 nocturnal hom e HD patients were com pared, m atched with conventional HD patients, study results indicated that death rate was 6.1 per 100 patient years in nocturnal hom e HD and 10.5 in conventional centre HD reflecting 45% less m ortality risk in nocturnal hom e HD. Slide 27 This is another survival analysis evaluating patient survival treated with nocturnal hom e HD in com parison with transplant patients and study results dem onstrated that nocturnal hom e HD provides a survival rate sim ilar to that in cadaveric renal transplantation. Slide 28
This recent study published in the New England Journal of Medicine shows m uch higher event rates on the day after the long intradialytic interval than on other days in conventional HD patients. What m ight be the solution? Every other day HD m ight be a solution. It m ay be difficult in centre HD conditions but it s perfectly applicable in hom e HD cases. Slide 29 This study evaluated em ploym ent rate in dialysis and transplant patients and they reported m arkedly high probability of em ploym ent in hom e HD patients com pared to those on centre HD. Slide 30
What do nephrologists think about optim al renal replacem ent therapy m odality? The first part or piece of nephrologists and the second part the facts. Of nephrologists only 22% believe that conventional 4-hour three tim es centre HD is the optim al m odality. However, 85% of patients are treated with conventional centre HD. Of nephrologists 34% believe that hom e HD is the optim al m odality. However, only 4% of patients are treated with hom e HD. Slide 31 What about the cost of renal replacem ent therapy? This study com es from Canada and shows lower costs in hom e HD than in centre HD. Slide 32
What is good dialysis? Slide 33 We had 3 m onths training. After 3 m onths I started doing hom e hem odialysis and it has already been 5-6 m onths. Very com fortable, very nice and everything is going perfectly well. I feel very confident now as if I had been a nurse for years. We do all the procedures as if I am going to bed or to sleep and so com fortably. She does not take ESA. She does not take any m edication for bones or phosphorous, right? She is not taking any of those m edications at all and all her lab results are norm al. She has no problem s such as hypertension. I do not lack anything now that I had in m y norm al life. Nobody can see m e sitting for 5 m inutes from the m om ent I wake up until I go to bed. I am always active. For exam ple, now we have a garden. We grow peppers, lettuce, onions, garlic there. Whatever we need we have it in our garden. She hoes, waters and collects them. She m akes pickles and tom ato pastes. Well, she never says she is ill, she is actually not ill. I m ean she is labelled as a patient but she is not actually ill. Slide 34
She s a 57 year old lady, one of our first hom e HD patients I think this is good dialysis. Slide 35 Every other day, nocturnal, preferably at hom e. Slide 36
Thank you very m uch for your attention.