Preservation of Residual Renal Function with Limited Water Removal in Hemodialysis Patients

Abstract

Residual renal function (RRF) is of paramount importance for hemodialysis (HD) adequacy, morbidity, and mortality. Some studies have shown that overhydration is beneficial for preservation of RRF, but it can also increase the probability of adverse events such as hypertension and heart failure in HD patients. To determine the optimal amount of dehydration, we performed HD with limited water removal in HD patients. Eighteen HD patients included in this self-controlled study underwent HD with limited water removal. Water removal volume was determined by a previous volume as follows. Total water removal volume was divided into levels: ≤3.0, 3.0-9.0, and >9.0 L per week. Water removal was performed to obtain dry weight in the last dialysis, and was performed three times with a ratio of 1:1:2 and 2:2:3, respectively. Urine volume, endogenous creatinine clearance rate, Kt/V, hemoglobin, and serum albumin were recorded before and after the study at 3, 6, 9, and 12 months. The follow-up period was 12 months. Ten patients withdrew from the study because of adverse events including hypertension (n = 3), heart failure (n = 3), angina (n = 1), polycystic kidney rupture (n = 1), obvious edema (n = 1), and one patient had too much interdialytic weight gain to continue. As a result, we stopped this study after 1 month. Our data suggest that the preservation of RRF with limited water removal in HD patients must be interpreted with caution.

Effect of frequent hemodialysis on residual kidney function

“…One recent intervention in this particular direction, however, was unsuccessful, with 10 of 18 of patients withdrawing from the study because of adverse events. 41 Techniques to minimize platelet activation during dialysis might reduce this process and help preserve RKF. While use of more “biocompatible” synthetic membranes may reduce platelet activation, 42 in the FHN trial, membranes largely believed to be biocompatible were used.…”

Twice-Weekly and Incremental Hemodialysis Treatment for Initiation of Kidney Replacement Therapy

“…8–10 Nevertheless, mortality is the highest in the first several months of dialysis therapy 4 when most patients starting kidney replacement therapy have their highest RKF. The loss of RKF is faster in patients on HD than those receiving peritoneal dialysis (PD).…”

“…The loss of RKF is faster in patients on HD than those receiving peritoneal dialysis (PD). 10, 11 HD may cause episodic ischemic damage to the kidneys, leading to repetitive bouts of ischemic events similar to acute kidney injury (AKI). 8, 9 Notwithstanding the ongoing debate about the causal link between AKI and subsequent CKD 12 and that the use of the term “AKI” may not be appropriate for the mechanism of the faster loss of RKF in HD patients, the cumulative effect of repetitive ischemic events may accelerate the decline in RKF.…”

What Is Known and Unknown About Twice-Weekly Hemodialysis

“…It has also been associated with higher HRQoL, lower inflammation, reduced left ventricular hypertrophy, and better survival. However, RKF decline is faster in patients receiving thrice-weekly HD therapy than in those receiving peritoneal dialysis [21] ; whereas HD per se may accelerate RKF decline by episodic ischemic insults to the kidney, provision of less frequent HD may mitigate this potential risk of HD. Indeed, consistent with the results from the FHN study that showed faster loss of RKF in frequent nocturnal HD compared with conventional thrice-weekly HD [18], several non-controlled clinical studies indicated that twice-weekly HD may preserve RKF [22–24].…”