Yoshitsugu Obi1, Elani Streja1, Connie M Rhee1, Vanessa Ravel1, Alpesh N Amin2, Adamasco Cupisti3, Jing Chen4, Anna T Mathew5, Csaba P Kovesdy6, Rajnish Mehrotra7, Kamyar Kalantar-Zadeh8. 1. Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA. 2. Department of Medicine, University of California Irvine, Orange, CA. 3. Division of Nephrology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy. 4. Division of Nephrology, Huashan Hospital, Fudan University, Yangpu, Shanghai, China. 5. Hofstra North Shore-LIJ School of Medicine, Division of Kidney Diseases and Hypertension, North Shore-LIJ Health System, Great Neck, NY. 6. Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN. 7. Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA. 8. Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA; Fielding School of Public Health at UCLA, Los Angeles, CA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA. Electronic address: kkz@uci.edu.
Abstract
BACKGROUND: Maintenance hemodialysis is typically prescribed thrice weekly irrespective of a patient's residual kidney function (RKF). We hypothesized that a less frequent schedule at hemodialysis therapy initiation is associated with greater preservation of RKF without compromising survival among patients with substantial RKF. STUDY DESIGN: A longitudinal cohort. SETTING & PARTICIPANTS: 23,645 patients who initiated maintenance hemodialysis therapy in a large dialysis organization in the United States (January 2007 to December 2010), had available RKF data during the first 91 days (or quarter) of dialysis, and survived the first year. PREDICTOR: Incremental (routine twice weekly for >6 continuous weeks during the first 91 days upon transition to dialysis) versus conventional (thrice weekly) hemodialysis regimens during the same time. OUTCOMES: Changes in renal urea clearance and urine volume during 1 year after the first quarter and survival after the first year. RESULTS: Among 23,645 included patients, 51% had substantial renal urea clearance (≥3.0mL/min/1.73m(2)) at baseline. Compared with 8,068 patients with conventional hemodialysis regimens matched based on baseline renal urea clearance, urine volume, age, sex, diabetes, and central venous catheter use, 351 patients with incremental regimens exhibited 16% (95% CI, 5%-28%) and 15% (95% CI, 2%-30%) more preserved renal urea clearance and urine volume at the second quarter, respectively, which persisted across the following quarters. Incremental regimens showed higher mortality risk in patients with inadequate baseline renal urea clearance (≤3.0mL/min/1.73m(2); HR, 1.61; 95% CI, 1.07-2.44), but not in those with higher baseline renal urea clearance (HR, 0.99; 95% CI, 0.76-1.28). Results were similar in a subgroup defined by baseline urine volume of 600mL/d. LIMITATIONS: Potential selection bias and wide CIs. CONCLUSIONS: Among incident hemodialysis patients with substantial RKF, incremental hemodialysis may be a safe treatment regimen and is associated with greater preservation of RKF, whereas higher mortality is observed after the first year of dialysis in those with the lowest RKF. Clinical trials are needed to examine the safety and effectiveness of twice-weekly hemodialysis.
BACKGROUND: Maintenance hemodialysis is typically prescribed thrice weekly irrespective of a patient's residual kidney function (RKF). We hypothesized that a less frequent schedule at hemodialysis therapy initiation is associated with greater preservation of RKF without compromising survival among patients with substantial RKF. STUDY DESIGN: A longitudinal cohort. SETTING & PARTICIPANTS: 23,645 patients who initiated maintenance hemodialysis therapy in a large dialysis organization in the United States (January 2007 to December 2010), had available RKF data during the first 91 days (or quarter) of dialysis, and survived the first year. PREDICTOR: Incremental (routine twice weekly for >6 continuous weeks during the first 91 days upon transition to dialysis) versus conventional (thrice weekly) hemodialysis regimens during the same time. OUTCOMES: Changes in renal urea clearance and urine volume during 1 year after the first quarter and survival after the first year. RESULTS: Among 23,645 included patients, 51% had substantial renal urea clearance (≥3.0mL/min/1.73m(2)) at baseline. Compared with 8,068 patients with conventional hemodialysis regimens matched based on baseline renal urea clearance, urine volume, age, sex, diabetes, and central venous catheter use, 351 patients with incremental regimens exhibited 16% (95% CI, 5%-28%) and 15% (95% CI, 2%-30%) more preserved renal urea clearance and urine volume at the second quarter, respectively, which persisted across the following quarters. Incremental regimens showed higher mortality risk in patients with inadequate baseline renal urea clearance (≤3.0mL/min/1.73m(2); HR, 1.61; 95% CI, 1.07-2.44), but not in those with higher baseline renal urea clearance (HR, 0.99; 95% CI, 0.76-1.28). Results were similar in a subgroup defined by baseline urine volume of 600mL/d. LIMITATIONS: Potential selection bias and wide CIs. CONCLUSIONS: Among incident hemodialysis patients with substantial RKF, incremental hemodialysis may be a safe treatment regimen and is associated with greater preservation of RKF, whereas higher mortality is observed after the first year of dialysis in those with the lowest RKF. Clinical trials are needed to examine the safety and effectiveness of twice-weekly hemodialysis.
Authors: Allan J Collins; Robert N Foley; Blanche Chavers; David Gilbertson; Charles Herzog; Areef Ishani; Kirsten Johansen; Bertram L Kasiske; Nancy Kutner; Jiannong Liu; Wendy St Peter; Haifeng Guo; Yan Hu; Allyson Kats; Shuling Li; Suying Li; Julia Maloney; Tricia Roberts; Melissa Skeans; Jon Snyder; Craig Solid; Bryn Thompson; Eric Weinhandl; Hui Xiong; Akeem Yusuf; David Zaun; Cheryl Arko; Shu-Cheng Chen; Frank Daniels; James Ebben; Eric Frazier; Roger Johnson; Daniel Sheets; Xinyue Wang; Beth Forrest; Delaney Berrini; Edward Constantini; Susan Everson; Paul Eggers; Lawrence Agodoa Journal: Am J Kidney Dis Date: 2014-01 Impact factor: 8.860
Authors: John T Daugirdas; Thomas A Depner; Tom Greene; Nathan W Levin; Glenn M Chertow; Michael V Rocco Journal: Kidney Int Date: 2010-01-27 Impact factor: 10.612
Authors: Brian Bieber; Jiaqi Qian; Shuchi Anand; Yucheng Yan; Nan Chen; Mia Wang; Mei Wang; Li Zuo; Fan Fan Hou; Ronald L Pisoni; Bruce M Robinson; Sylvia P B Ramirez Journal: Nephrol Dial Transplant Date: 2013-12-08 Impact factor: 5.992
Authors: Yoshitsugu Obi; Connie M Rhee; Anna T Mathew; Gaurang Shah; Elani Streja; Steven M Brunelli; Csaba P Kovesdy; Rajnish Mehrotra; Kamyar Kalantar-Zadeh Journal: J Am Soc Nephrol Date: 2016-05-11 Impact factor: 10.121
Authors: Jeffrey Perl; Laura M Dember; Joanne M Bargman; Teri Browne; David M Charytan; Jennifer E Flythe; LaTonya J Hickson; Adriana M Hung; Michel Jadoul; Timmy Chang Lee; Klemens B Meyer; Hamid Moradi; Tariq Shafi; Isaac Teitelbaum; Leslie P Wong; Christopher T Chan Journal: Clin J Am Soc Nephrol Date: 2017-03-17 Impact factor: 8.237
Authors: Kamyar Kalantar-Zadeh; Csaba P Kovesdy; Elani Streja; Connie M Rhee; Melissa Soohoo; Joline L T Chen; Miklos Z Molnar; Yoshitsugu Obi; Daniel Gillen; Danh V Nguyen; Keith C Norris; John J Sim; Steve S Jacobsen Journal: Nephrol Dial Transplant Date: 2017-04-01 Impact factor: 5.992
Authors: Sheldon C Leong; Justin N Sao; Abigail Taussig; Natalie S Plummer; Timothy W Meyer; Tammy L Sirich Journal: J Am Soc Nephrol Date: 2018-05-04 Impact factor: 10.121