By Dr. Robert Provenzano
Most people are aware that dialysis is a lifesaving treatment for people with kidney failure. But the evolution of dialysis has not kept pace with the changing lifestyles of those who depend on this treatment.
For many years, the administration of dialysis therapy was somewhat of a guessing game. With the advent of the ability to measure delivered dialysis (Kt/V, which measures adequacy of dialysis or how well the blood is being cleaned) in the late 1980s, three times a week dialysis, for three to four hours, became the standard for dialysis delivery. Dialysis schedules were therefore based on this frequency so that traditional in-center dialysis is now scheduled three times a week; either Monday, Wednesday and Friday or Tuesday, Thursday and Saturday.
One secret that many dialysis professionals know, but often remains unspoken, is that the more dialysis you receive the better you do. Many years ago data from Europe, specifically from France, showed that longer in-center treatments of six to eight hours three to five times a week resulted in markedly improved clinical outcomes and an increased sense of well-being for patients. Additionally, these dialysis patients were on less blood pressure medications, required less erythrocyte stimulating proteins (EPO to treat anemia) and were able to enjoy a much more liberal diet.
A healthy person’s kidneys work everyday: 24 hours a day, 7 days a week (168 hours/week) to remove excess water and clean the blood. Even diseased kidneys are constantly functioning, although at a lower level. Traditional, three times a week dialysis, must try to accomplish in 12 hours a week what functioning kidneys would do in 168 hours. This often results in drops in blood pressure and less cleansing of the blood than if the process lasted longer.
In the 1970s and early 1980s, there were a large number of patients receiving home dialysis, and many of these patients chose home dialysis because they wanted to control their own care. The clinical outcomes of these home dialysis patients mimicked those who received extended intermittent dialysis as reported from Europe. These home dialysis patients also had fewer dialysis access infections, an improved sense of well-being and were able to enjoy more liberal diets.
The home dialysis patients integrated their therapies into their lifestyles, dialyzing themselves, four, five, six or even seven days for two to four hours at a time. They received more total dialysis than was delivered in the in-center hemodialysis settings.
Now let’s flash forward. Dialysis professionals are dialyzing people in the 21st century and have the knowledge and data that states more dialysis is better. More and more dialysis patients are choosing to remain employed, remain engaged in their families and are looking for broader dialysis options. As health care providers, part of our responsibility is to provide our patients with a variety of dialysis therapy options that fit their needs including extended forms of dialysis therapy.
There are two major types of extended dialysis therapy: at-home dialysis and in-center nocturnal dialysis. At-home dialysis includes a choice between peritoneal dialysis (PD) and home hemodialysis. In-center nocturnal
dialysis provides dialysis in the environment of an outpatient dialysis facility. Patients arrive at the dialysis center in the evening and start their treatment any time from 8:00 p.m. to 9:00 p.m., and complete their treatment between 4:00 a.m. to 6:00 a.m. In-center nocturnal dialysis patients are provided with a chair or bed (where available); they typically bring their own personal bedding, wear their pajamas, surround themselves with all the comforts of home and are able to sleep while receiving their dialysis therapy.
As opposed to shorter, three times a week dialysis, the blood flows for nocturnal dialysis are lower, generally 200 ml/min. The dialysate flows are also lower at 300 to 400 ml/min. These lowered flows and the extended treatment times allow for a more gentle ultrafiltration, which is especially important for patients with advanced cardiac disorders (heart trouble) and chronic hypotension (low blood pressure).
Ncturnal dialysis patients have the option of dialyzing three or more times a week with this therapy. Early data has shown an improved sense of well-being as well as improvements in many of the parameters that are used to measure quality dialysis therapy. Certainly, nocturnal dialysis is one instance where more is better.
Additionally, with nocturnal dialysis, patients have their entire day free to maintain a normal lifestyle, doing what they believe adds meaning and quality to their lives.
Everyone! There are often initial fears that nocturnal dialysis patients might be at increased risk or that physicians would be uncomfortable and concerned with their patients’ safety if they are dialyzing while they sleep, but this has never been shown to be true. Nocturnal dialysis patients tend to have uneventful, predictable dialysis treatments. Indeed, polling medical directors of nocturnal dialysis programs showed their initial safety fears were unfounded and that they are rarely disproportionately called on for nocturnal patients. Nocturnal dialysis patients tend to have uneventful, predictable dialysis treatments.
Let me get back to my earlier statement about options. As responsible care providers, broadening our palette of options for our dialysis patients is certainly the right thing to do. Seeing to it that the right dialysis patient gets the right dialysis treatment at the right times is more critical today than ever before. Offering the option of nocturnal dialysis therapy should be implemented as soon as end stage renal disease (ESRD) patients are identified, either in the hospital if they are an "acute crash" to dialysis, or in a chronic kidney disease (CKD) program. Increased focus on assisting dialysis patients to remain employed, insured and in control of their lives should not be overlooked. I am personally convinced that kidney patients on nocturnal dialysis will continue to accumulate the long-term benefits of additional dialysis currently not available to the patients being treated in a traditional daytime hemodialysis program.
Robert Provenzano, MD, FACP, is a nephrologist in Detroit, Michigan. He is Chair of the Division of Nephrology, Hypertension and Transplantation and Associate Professor of Medicine at Wayne State University.
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