CURRENT STATUS OF ALTERNATIVE HEMODIALYSIS REGIMENS
Alternate Night Nocturnal Hemodialysis: The Australian Experience Peter G. Kerr,* John W. M. Agar,† and Carmel M. Hawley‡ *Department of Nephrology, Monash Medical Centre and Monash University, Clayton, Victoria, Australia, †Department of Renal Medicine, Geelong Hospital, Geelong, Victoria, Australia, and ‡Department of Nephrology, Princess Alexandra Hospital, Woollongabba, Queensland, Australia
ABSTRACT Alternate night nocturnal hemodialysis (HD) is a popular modality in Australia. This modality grew out of a desire to increase the availability and accessibility of nocturnal HD without incurring excessive costs. It has proven popular with staff, patients, and administrators. There are limited data to support the benefits of this modality and undoubtedly, more data are required. As in 5–6 times per
week nocturnal HD, the major benefits appear to be in phosphate control, volume control, and patient wellbeing. Economically, this approach to nocturnal HD costs much the same as conventional home HD, with only one extra dialysis session every 2 weeks. This review expands on some aspects of this dialysis modality and how it is practiced in Australia.
Historical Perspective
version, but are biased by including predominantly younger, home HD patients (2,3). Whilst this approach costs more in terms of consumables, due to one extra dialysis session every 2 weeks, the funding model in some States of Australia made this feasible. As nocturnal dialysis started to become popular, primarily through the efforts of John Agar in Geelong, it was an economically easy step to go from 3.5 times per week conventional home HD to 3.5 times per week overnight dialysis––with essentially no added costs. The lower dialysate flow utilized in the majority of nocturnal HD programs (300 ml ⁄ minute compared with 500 ml ⁄ minute) means that consumable costs were the same for conventional and nocturnal sessions. Since 2002–2003, this modality has gradually increased around several centers in Australia. For most units employing this approach, 5–6 times per week nocturnal dialysis is reserved for particular patients, often for those with very large body mass indexes who are felt to require the additional clearances offered by more frequent nocturnal HD.
Alternate night (or 3.5 times per week) nocturnal hemodialysis (HD) is a popular mode of home HD in Australia, accounting for 32% of all home HD and 89% of all nocturnal HD (1). In units that favor this modality, very few patients are now trained in conventional home HD, with more than 90% of new patients in home HD being trained for alternate night nocturnal HD. This modality arose at around the same time as more frequent nocturnal HD gained traction in Australia. Prior to that, some units had already decided that the long weekend break was not offering optimal treatment for their patients. As home HD offered the option of a flexible schedule, units were starting to utilize 3.5 times per week dialysis for ‘‘conventional’’ home HD. The avoidance of the long break was felt to be better in terms of avoiding the larger solute and fluid accumulation associated with this. In particular, the avoidance of the larger fluid accumulation offered potential benefits in terms of blood pressure control and left ventricular hypertrophy––although this has never been formally put to trial. Observational data from the ANZDATA registry comparing 3.5· with 3· per week HD demonstrate markedly improved outcomes for the more frequent
Prescription The common model of 3.5 times per week nocturnal HD in Australia involves: • Use of a standard home dialysis machine (e.g., Fresenius 4008B series (Fresenius, Bad Homburg, Germany) or Gambro AK96 or AK200 series (Gambro, Lund, Sweden)) • Typically 8-hour sessions • Blood flow rates of 200–250 ml ⁄ minute
Address correspondence to: Peter G. Kerr, Director of Nephrology, Monash Medical Centre, 246 Clayton Rd, Clayton, Vic. 3168, Australia, Tel.: 61-3-9594-3524, Fax: 61-3-9594-6530, or e-mail:
[email protected]. Seminars in Dialysis—Vol 24, No 6 (November–December) 2011 pp. 664–667 DOI: 10.1111/j.1525-139X.2011.00997.x ª 2011 Wiley Periodicals, Inc. 664
ALTERNATE NIGHT NOCTURNAL HEMODIALYSIS
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Dialysate flow rates of 300 ml ⁄ minute High-flux dialyzers, typically of 1.6–1.8 m2 surface area • Dialysate calcium of 1.25–1.50 mmol ⁄ l (2.5– 3.0 mEq ⁄ l) • Dialysate potassium of 2.0 mmol ⁄ l • No remote monitoring • 24-hour nurse on-call backup • Various approaches to blood leak detection–– from none to ‘‘incontinence pads’’ or recently to Redsense (Redsense Medical AB, Halmstad, Sweden) monitors • Predominantly rope ladder needling, with limited button-hole cannulation • Patients are reviewed in clinic every 2– 3 months; for most patients, this represents their only medical contact. This is a major difference from US practice where monthly visits are demanded by funding bodies. Most Australian nephrologists are very comfortable with this and, at least anecdotally, do not believe that more frequent visits are required. Overall, the Australian impression is that 3.5 times per week nocturnal HD offers very good outcomes. ANZDATA has reported markedly increased survival for patients receiving 18 or more dialysis hours per week compared with 12 hours, and also for 3.5 times per week dialysis frequency compared with 3 times per week (2,3). More recently, a careful and detailed analysis by Mark Marshall has demonstrated significantly improved survival for home HD compared with PD or facility HD–– with home HD comprising more than 35% nocturnal or extended hours dialysis (4). Both of these are registry analyses and are subject to the biases of observational data, as well as selection bias for those electing to dialyze at home. There is no doubt that staff and patients alike are convinced of the improvements in wellbeing derived from this modality. A randomized controlled trial of extended hours versus conventional dialysis is currently underway, with the primary endpoint being quality of life, ACTIVE Dialysis trial (Clinical Trials.gov number: NCT00649298). Biochemical and Clinical Outcomes In an attempt to assess the value of 3.5· nocturnal HD with the more widely known 5–6· nocturnal HD, we conducted a comparison study, spread across two units in the State of Victoria (5). Both units employed 7– 8-hour sessions, dialysate flow rates of 300 ml ⁄ minute, and blood flow rates of 225–250 ml ⁄ minute. The 3.5· unit employed 1.8 m2 high-flux dialyzers, whilst the 5–6· unit employed 1.6–1.8 m2 low-flux dialyzers. Not surprisingly, the urea reduction ratio for the individual sessions was similar (at approx. 77%), although the predialysis serum urea levels were 10.16 ± 2.08 mmol ⁄ l for the 5–6· group and 19.54 ± 7.06 for the 3.5· group. Probably, the most pertinent difference was in predialysis serum phosphate, which was 1.64 ± 0.36 and 1.88 ± 0.55 mmol ⁄ l, respectively. None of the 5–6· group was taking phosphate binders compared with
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38% of the 3.5· group. Furthermore, all of the 5–6· groups were receiving phosphate supplementation in their dialysate, compared with 19% of the 3.5· group. Parathyroid hormone and hemoglobin levels, as well as erythropoietin usage, were not different between the groups. Another similar analysis from the Brisbane group showed comparable results for 3.5· nocturnal HD (6). After 12 months of 3.5· nocturnal HD, 77.2% of patients needed no phosphate binders and 22.7% required phosphate supplementation in the dialysate. Assessing the achievement of Kidney Disease Outcomes and Quality Initiative (KDOQI) targets (as they were defined at the time), the Brisbane group was able to demonstrate, after 12 months of 3.5· nocturnal HD, that 86% of patients met the serum phosphate target of
