Meeting News

Nephrologists debate whether more frequent or incremental hemodialysis is best choice

Two nephrologists discussed their reasons for being proponents of either more frequent or incremental hemodialysis at the virtual National Kidney Foundation Spring Clinical Meetings.

Karthik Tennankore, MD, FRCPC, of Dalhousie University in Canada, contended that more frequent hemodialysis bestows some “very important benefits,” which have been demonstrated in several randomized controlled trials.

He first cited a study that found patients on frequent hemodialysis had improvements in blood pressure at 12 months which, he emphasized, was “in the face of the reduction of antihypertensive medications.”

Furthermore, while hyperphosphatemia is a concern, one study determined patients on more frequent dialysis saw improvements in phosphate, as well as a drop in the number of phosphate binder prescriptions.

“When patients get to reduce their pill burden, that’s a huge benefit,” he said.

In addition, he indicated that frequent dialysis patients may have reduced recovery time after a treatment (60 minutes less than those on incremental, according to one study).

Finally, he suggested that daily hemodialysis patients had a 50% reduction in relative mortality hazard. Noting that patients are at the highest risk for death after the break between dialysis sessions (and incremental dialysis necessitates longer breaks), Tennankore put forth the idea that incremental dialysis can lead to higher all-cause mortality, infection-related mortality and mortality due to cardiac causes.

While he conceded there is “a signal to more vascular access complications” with frequent hemodialysis, he maintained there are not enough data related to vascular access for patients on incremental dialysis.

“Incremental dialysis does not have the evidence base yet for widespread implementation,” he concluded. “Frequent hemodialysis does have a number of risks along with the benefits, but I don’t think these risks outweigh the benefits. Further, there are ways to modify, and be flexible with, the treatment for those who are at a perceived higher risk.”

Kamyar Kalantar-Zadeh

Kamyar Kalantar-Zadeh, MD, MPH, PhD, of University of California Irvine, provided a different perspective, arguing: “It’s been 50 years since President Nixon signed the ESRD legislation, and it is still essentially unknown as to why and how we start patients on dialysis. We’re struggling with early vs. late and so many other things. I’m here to say that all of these questions become irrelevant if you start patients gradually on dialysis based on precision medicine in ESRD.”

Kalantar-Zadeh stressed the importance of residual kidney function, noting patients often experience a drop in residual kidney function in 1 year of starting dialysis. He asked, “Is this a natural progression or is this because of what we did to them?”

According to Kalantar-Zadeh, frequent dialysis accelerates loss of residual kidney function and “there is no question about this.”

One way to maintain residual kidney function, he said, is to start patients on twice-weekly hemodialysis instead of thrice-weekly treatment. While the assumption is that physicians should start all patients on thrice-weekly dialysis, Kalantar-Zadeh contended that abrupt transition to dialysis is why mortality is so high.

His recommendation is to start patients gradually on dialysis (once a week) and then move to two times per week. As their condition deteriorates, then hemodialysis can be administered more frequently though, after 30 or 40 years, lower frequency with palliative dialysis should be considered.

“Any gradual or incremental dialysis gives a smoother transition and gives freedom to the patient,” he said, noting that the harms of dialysis are less common in incremental dialysis. One harm of frequent dialysis he mentioned was related to vascular access (arteriovenous fistula or graft). “It’s not rocket science,” he said. “If you poke the arm more frequently, you’re going to cause damage.”

In our current situation, he also suggested that if a patient goes to dialysis more frequently, that patient is more likely to be exposed to COVID-19.

Kalantar-Zadeh concluded, “With precision medicine, the age of one size fits all is over. You can have different types of incremental dialysis, which preserve residual kidney function based on consistent data.” – by Melissa J. Webb

Reference:

Kalantar-Zadeh K and Tennankore K. Session #261. Presented at: National Kidney Foundation Spring Clinical Meetings; March 26-29, 2020. (virtual meeting).

Disclosures: Healio Nephrology was unable to determine relevant financial disclosures prior to publication.

Two nephrologists discussed their reasons for being proponents of either more frequent or incremental hemodialysis at the virtual National Kidney Foundation Spring Clinical Meetings.

Karthik Tennankore, MD, FRCPC, of Dalhousie University in Canada, contended that more frequent hemodialysis bestows some “very important benefits,” which have been demonstrated in several randomized controlled trials.

He first cited a study that found patients on frequent hemodialysis had improvements in blood pressure at 12 months which, he emphasized, was “in the face of the reduction of antihypertensive medications.”

Furthermore, while hyperphosphatemia is a concern, one study determined patients on more frequent dialysis saw improvements in phosphate, as well as a drop in the number of phosphate binder prescriptions.

“When patients get to reduce their pill burden, that’s a huge benefit,” he said.

In addition, he indicated that frequent dialysis patients may have reduced recovery time after a treatment (60 minutes less than those on incremental, according to one study).

Finally, he suggested that daily hemodialysis patients had a 50% reduction in relative mortality hazard. Noting that patients are at the highest risk for death after the break between dialysis sessions (and incremental dialysis necessitates longer breaks), Tennankore put forth the idea that incremental dialysis can lead to higher all-cause mortality, infection-related mortality and mortality due to cardiac causes.

While he conceded there is “a signal to more vascular access complications” with frequent hemodialysis, he maintained there are not enough data related to vascular access for patients on incremental dialysis.

“Incremental dialysis does not have the evidence base yet for widespread implementation,” he concluded. “Frequent hemodialysis does have a number of risks along with the benefits, but I don’t think these risks outweigh the benefits. Further, there are ways to modify, and be flexible with, the treatment for those who are at a perceived higher risk.”

Kamyar Kalantar-Zadeh

Kamyar Kalantar-Zadeh, MD, MPH, PhD, of University of California Irvine, provided a different perspective, arguing: “It’s been 50 years since President Nixon signed the ESRD legislation, and it is still essentially unknown as to why and how we start patients on dialysis. We’re struggling with early vs. late and so many other things. I’m here to say that all of these questions become irrelevant if you start patients gradually on dialysis based on precision medicine in ESRD.”

Kalantar-Zadeh stressed the importance of residual kidney function, noting patients often experience a drop in residual kidney function in 1 year of starting dialysis. He asked, “Is this a natural progression or is this because of what we did to them?”

According to Kalantar-Zadeh, frequent dialysis accelerates loss of residual kidney function and “there is no question about this.”

One way to maintain residual kidney function, he said, is to start patients on twice-weekly hemodialysis instead of thrice-weekly treatment. While the assumption is that physicians should start all patients on thrice-weekly dialysis, Kalantar-Zadeh contended that abrupt transition to dialysis is why mortality is so high.

His recommendation is to start patients gradually on dialysis (once a week) and then move to two times per week. As their condition deteriorates, then hemodialysis can be administered more frequently though, after 30 or 40 years, lower frequency with palliative dialysis should be considered.

“Any gradual or incremental dialysis gives a smoother transition and gives freedom to the patient,” he said, noting that the harms of dialysis are less common in incremental dialysis. One harm of frequent dialysis he mentioned was related to vascular access (arteriovenous fistula or graft). “It’s not rocket science,” he said. “If you poke the arm more frequently, you’re going to cause damage.”

In our current situation, he also suggested that if a patient goes to dialysis more frequently, that patient is more likely to be exposed to COVID-19.

Kalantar-Zadeh concluded, “With precision medicine, the age of one size fits all is over. You can have different types of incremental dialysis, which preserve residual kidney function based on consistent data.” – by Melissa J. Webb

Reference:

Kalantar-Zadeh K and Tennankore K. Session #261. Presented at: National Kidney Foundation Spring Clinical Meetings; March 26-29, 2020. (virtual meeting).

Disclosures: Healio Nephrology was unable to determine relevant financial disclosures prior to publication.

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