Chronic Hemodialysis Therapy in the West

Abstract

Background: Chronic hemodialysis (HD) in the 1960s encompassed a wide variety of prescriptions from twice weekly to five times per week HD. Over time, HD prescriptions in the West became standardized at three times per week, 2.5-4 h per session, with occasional additional treatments for volume overload. Summary: When clinical trials of dialysis dose failed to show significant benefit of extending time compared with the traditional dialysis prescription, interest in more frequent HD was renewed. Consequently, there has been growth in home HD therapies as well as alternative dialysis prescriptions. Data from recent randomized clinical trials have demonstrated the benefits and risks of these more frequent therapies, with surprising differences in outcomes between short daily HD and long nocturnal HD. More frequent therapies improve control of both hypertension and hyperphosphatemia, but at the expense of increased vascular access complications and, at least for nocturnal HD, a faster loss of residual renal function. Key Messages: In the West, the standard HD prescription is three treatments per week with a minimal time of 3.0 h and dialysis is performed in an outpatient dialysis center. A minority of patients will have a fourth treatment per week for volume issues. Alternative HD prescriptions, although rare, are more available compared to the recent past. Facts from East and West: (1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.

Cerebral blood flow characteristics following hemodialysis initiation in older adults: A prospective longitudinal pilot study using arterial spin labeling imaging

“…In the United States, hemodialysis is the dominant renal replacement therapy. Approximately 88% of patients with diagnosed ESRD initiate hemodialysis, and a majority of them are aged older than 55 years ( United States Renal Data System, 2017 , Rocco, 2015 ). Up to 70% of older hemodialysis patients have moderate to severe cognitive impairment (CI), a higher prevalence than in matched pre-dialysis CKD and non-CKD populations ( Murray et al, 2006 , Murray, 2008 ).…”

It is time to implement prepump arterial pressure monitoring during hemodialysis: A retrospective multicenter study

“…In our study, the patients with more frequent hemodialysis and higher CCIs had a higher risk for AVF dysfunction. The contribution of a higher hemodialysis frequency to VA complications has also been reported; 24,25 however, benefits such as decreased morbidity and mortality from a higher hemodialysis frequency have also been highlighted. 25,26 To balance these two outcomes, it is important to implement better methods to maintain AVF to support more frequent hemodialysis.…”

Effects of far infrared therapy on arteriovenous fistulas in hemodialysis patients: a meta-analysis

“…In 1966, the development of a more durable AVFs by Dr. Cimino leads HD becoming more feasible [28]. Nowadays, it is estimated that there are more than 3 million patients with ESRD in Western countries [29], and two-thirds are treated with HD. Many clinical practice guidelines endorse the AVFs as the preferred form of vascular access due to it is associated with fewer complications compared to other vascular access (e.g., central venous catheter).…”