The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis

The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis.BackgroundHome nocturnal hemodialysis is an intensive form of hemodialysis, where patients perform their treatments at home for about 7hours approximately 6 nights a week. Compared with in-center conventional hemodialysis, home nocturnal hemodialysis has been shown to improve physiologic parameters and reduce health care costs; however, the effects on quality of life and cost utility are less clear. We hypothesized that individuals performing home nocturnal hemodialysis would have a higher quality of life and superior cost utility than in-center hemodialysis patients.MethodsHome nocturnal hemodialysis patients and a demographically similar group of in-center hemodialysis patients from a hospital without a home hemodialysis program underwent computer-assisted interviews to assess their utility score for current health by the standard gamble method.ResultsNineteen in-center hemodialysis and 24 home nocturnal hemodialysis patients were interviewed. Mean annual costs for home nocturnal hemodialysis were about $10,000 lower for home nocturnal hemodialysis ($55,139 ±$7651 for home nocturnal hemodialysis vs.$66,367 ±$17,502 for in-center hemodialysis, P = 0.03). Home nocturnal hemodialysis was associated with a higher utility score than in-center hemodialysis (0.77 ± 0.23 vs. 0.53 ± 0.35, P = 0.03). The cost utility for home nocturnal hemodialysis was$71,443/quality-adjusted life-year (QALY), while for in-center hemodialysis it was $125,845/QALY. Home nocturnal hemodialysis was the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of -$45,932. The 95% CI for the ICER, and 2500 bootstrap iterations of the ICER all fell below the cost-effectiveness ceiling of $50,000. The net monetary benefit of home nocturnal hemodialysis ranged from$11,227 to $35,669.ConclusionHome nocturnal hemodialysis is associated with a higher quality of life and a superior cost utility when compared to in-center hemodialysis

Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis

Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis.BackgroundLeft ventricular hypertrophy (LVH) is an independent risk factor for mortality in the dialysis population. LVH has been attributed to several factors, including hypertension, excess extracellular fluid (ECF) volume, anemia and uremia. Nocturnal hemodialysis is a novel renal replacement therapy that appears to improve blood pressure control.MethodsThis observational cohort study assessed the impact on LVH of conversion from conventional hemodialysis (CHD) to nocturnal hemodialysis (NHD). In 28 patients (mean age 44 ± 7 years) receiving NHD for at least two years (mean duration 3.4 ± 1.2 years), blood pressure (BP), hemoglobin (Hb), ECF volume (single-frequency bioelectrical impedance) and left ventricular mass index (LVMI) were determined before and after conversion. For comparison, 13 control patients (mean age 52 ± 15 years) who remained on self-care home CHD for one year or more (mean duration 2.8 ± 1.8 years) were studied also. Serial measurements of BP, Hb and LVMI were also obtained in this control group.ResultsThere were no significant differences between the two cohorts with respect to age, use of antihypertensive medications, Hb, BP or LVMI at baseline. After transfer from CHD to NHD, there were significant reductions in systolic, diastolic and pulse pressure (from 145 ± 20 to 122 ± 13mm Hg, P < 0.001; from 84 ± 15 to 74 ± 12mm Hg, P = 0.02; from 61 ± 12 to 49 ± 12mm Hg, P = 0.002, respectively) and LVMI (from 147 ± 42 to 114 ± 40 g/m2, P = 0.004). There was also a significant reduction in the number of prescribed antihypertensive medications (from 1.8 to 0.3, P < 0.001) and an increase in Hb in the NHD cohort. Post-dialysis ECF volume did not change. LVMI correlated with systolic blood pressure (r = 0.6, P = 0.001) during nocturnal hemodialysis. There was no relationship between changes in LVMI and changes in BP or Hb. In contrast, there were no changes in BP, Hb or LVMI in the CHD cohort over the same time period.ConclusionsReductions in BP with NHD are accompanied by regression of LVH

Impact of nocturnal hemodialysis on the variability of heart rate and duration of hypoxemia during sleep

Impact of nocturnal hemodialysis on the variability of heart rate and duration of hypoxemia during sleep.BackgroundNocturnal hemodialysis (NHD) alleviates uremia-related sleep apnea, a condition characterized by increased sympathetic activity and diminished heart rate (HR) variability. We tested the hypothesis that NHD reduces both hypoxemia and sympathetic neural contributions to HR variability during sleep.MethodsEpisodes of apnea and hypopnea and the duration of nocturnal hypoxemia during sleep were determined in 9 end-stage renal disease (ESRD) patients (age: 44 ± 2) (mean ± SEM) before and after conversion from conventional hemodialysis (CHD) to NHD, and in 10 control subjects (age: 45 ± 3) with normal renal function and without sleep apnea. Low frequency (LF) (0.05-0.15 Hz) and high frequency (HF) (0.15-0.5 Hz) HR spectral power during stage 2 sleep was calculated (Fast Fourier transformation). Patients were studied 4 times (1day before and on the night after their CHD session) and 6–15months after conversion to NHD, while receiving NHD and on a non-dialysis night.ResultsNHD decreased the frequency of apnea and hypopnea (from 29.7 ± 9.3 to 8.2 ± 2.0 episodes per hour, P = 0.02), and duration of nocturnal hypoxemia (from 13.9 ± 5.2 to 2.6 ± 1.9% of total sleep time, P = 0.02). As CHD recipients, ESRD patients had faster nocturnal heart rates (79 ± 2 vs. 58 ± 1min-1, P = 0.03) and lower HF (vagal) (78 ± 27 vs. 6726 ± 4556ms2, P = 0.001) spectral power than control subjects. After conversion to NHD, HR fell (from 79 ± 2 to 66 ± 1min-1, P = 0.03) and HF power increased (from 78 ± 27 to 637 ± 139ms2, P = 0.001). The HF/HF+LF ratio, an index of vagal HR modulation, was lower during CHD (0.16 ± 0.03 vs. 0.42 ± 0.05 in control subjects, P < 0.05) and increased (to 0.45 ± 0.05, P < 0.001) after conversion to NHD. The LF/HF ratio, a representation of sympathetic HR modulation, which was significantly higher during CHD than in control subjects (2.77 ± 0.82 vs. 0.71 ± 0.11, P < 0.05), was also normalized by NHD (0.74 ± 0.12, P < 0.05, compared with CHD).ConclusionHigher heart rates and impaired vagal and augmented sympathetic HR modulation during sleep in ESRD patients are normalized by NHD. Potential mechanisms for these observations include attenuation of surges in sympathetic outflow elicited by apnea and hypoxia during sleep, normalization of nocturnal breathing patterns that influence HRV, and removal, by increased dialysis, of a sympatho-excitatory stimulus of renal origin

Guided optimization of fluid status in haemodialysis patients

Background. Achieving normohydration remains a non-trivial issue in haemodialysis therapy. Guiding the haemodialysis patient on the path between fluid overload and dehydration should be the clinical target, although it can be difficult to achieve this target in practice. Objective and clinically applicable methods for the determination of the normohydration status on an individual basis are needed to help in the identification of an appropriate target weight

A case of Bartter syndrome type I with atypical presentations

Bartter syndrome (BS) is an autosomal recessively inherited rare renal tubular disorder characterized by hypokalemic metabolic alkalosis and hyperreninemic hyperaldosteronism with normal to low blood pressure due to a renal loss of sodium. Genetically, BS is classified into 5 subtypes according to the underlying genetic defects, and BS is clinically categorized into antenatal BS and classical BS according to onset age. BS type I is caused by loss-of-function mutations in the SLC12A1 gene and usually manifests as antenatal BS. This report concerns a male patient with compound heterozygous missense mutations on SLC12A1 (p.C436Y and p.L560P) and atypical clinical and laboratory features. The patient had low urinary sodium and chloride levels without definite metabolic alkalosis until the age of 32 months, which led to confusion between BS and nephrogenic diabetes insipidus (NDI). In addition, the clinical onset of the patient was far beyond the neonatal period. Genetic study eventually led to the diagnosis of BS type I. The low urinary sodium and chloride concentrations may be caused by secondary NDI, and the later onset may suggest the existence of a genotype-phenotype correlation

Habitual sleep and kidney function in chronic kidney disease: the Chronic Renal Insufficiency Cohort study

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142952/1/jsr12573.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142952/2/jsr12573_am.pd

The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial

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

Choosing to live with home dialysis-patients' experiences and potential for telemedicine support: a qualitative study

<p>Abstract</p> <p>Background</p> <p>This study examines the patients' need for information and guidance in the selection of dialysis modality, and in establishing and practicing home dialysis. The study focuses on patients' experiences living with home dialysis, how they master the treatment, and their views on how to optimize communication with health services and the potential of telemedicine.</p> <p>Methods</p> <p>We used an inductive research strategy and conducted semi-structured interviews with eleven patients established in home dialysis. Our focus was the patients' experiences with home dialysis, and our theoretical reference was patients' empowerment through telemedicine solutions. Three informants had home haemodialysis (HHD); eight had peritoneal dialysis (PD), of which three had automated peritoneal dialysis (APD); and five had continuous ambulatory peritoneal dialysis (CAPD). The material comprises all PD-patients in the catchment area capable of being interviewed, and all known HHD-users in Norway at that time.</p> <p>Results</p> <p>All of the interviewees were satisfied with their choice of home dialysis, and many experienced a normalization of daily life, less dominated by disease. They exhibited considerable self-management skills and did not perceive themselves as ill, but still required very close contact with the hospital staff for communication and follow-up. When choosing a dialysis modality, other patients' experiences were often more influential than advice from specialists. Information concerning the possibility of having HHD, including knowledge of how to access it, was not easily available. Especially those with dialysis machines, both APD and HHD, saw a potential for telemedicine solutions.</p> <p>Conclusions</p> <p>As home dialysis may contribute to a normalization of life less dominated by disease, the treatment should be organized so that the potential for home dialysis can be fully exploited. Pre-dialysis information should be unbiased and include access to other patients' experiences. Telemedicine may potentially facilitate a communication-based follow-up and improve safety within the home setting, making it easier to choose and live with home dialysis.</p

Cardiac and vascular structure and function parameters do not improve with alternate nightly home hemodialysis: An interventional cohort study

Background: Nightly extended hours hemodialysis may improve left ventricular hypertrophy and function and endothelial function but presents problems of sustainability and increased cost. The effect of alternate nightly home hemodialysis (NHD) on cardiovascular structure and function is not known