Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/Vurea, a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Thus, we were unable to demonstrate a definitive benefit of more frequent nocturnal hemodialysis for either coprimary outcome.

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Coronavirus disease 2019 (COVID-19), a pandemic sweeping the world's population, is particularly threatening to patients on dialysis. This concise publication brings the evidence-based guidance of the Centers for Disease Control and Prevention (CDC) and the practical judgment of dialysis clinicians, brought together by the American Society of Nephrology (ASN), to inform best practice for in-center hemodialysis. COVID-19 is a novel coronavirus disease caused by the severe acute respiratory syndrome coronavirus 2. Patients usually present with fever (44%-98%), cough (68%-76%), myalgia (18%), and fatigue (18%) (1,2). The infectivity of this virus is high enough to assure pandemic spread if no mitigating efforts are made to stop it. Based on data from the Diamond Princess cruise ship COVID-19 outbreak, the maximum-likelihood value of the reproductive number (R 0) was 2.8 (3). Mortality has been estimated at 1.4%-3.6% (1,2), but could be higher (4) or lower as case finding increases. Children weather the infections well, with few complications (5). Older age and comorbid hypertension, diabetes, neutrophilia, and organ and coagulation dysfunction are risk factors for adult respiratory distress syndrome and death (6). Because the approximately 0.5 million United States residents receiving maintenance dialysis treatment are primarily in this high-risk group, dialysis facilities and the professionals caring for these patients must be prepared to safely manage them and protect noninfected patients and staff from acquiring this infection. A recent report nicely describes what is currently known about COVID-19 infection and kidneys (7). During the Ebola epidemic of 2014, patients with suspected disease were generally referred to hospitals for diagnosis and treatment. Dialysis for patients with Ebola in the United States was provided exclusively in the inpatient setting, with the structural and procedural safeguards to prevent infection transmission. This was practical because the number of patients who were infected was small. Patients were referred to a few centers with the expertise to care for them. The challenge of COVID-19 is very different: as the disease spreads in a community, many patients on dialysis in the same geographic area are likely to become infected and require continued dialysis treatments. Thriceweekly dialysis poses the risk of infection spread among patients and staff. Early in this pandemic, patients on dialysis who are symptomatic may be referred to hospital for diagnosis and management.