Consequences of frequent hemodialysis: comparison to conventional hemodialysis and transplantation

Abstract

The average life expectancy of a person on hemodialysis is less than 3 years and hasn't changed in 20 years. The Hemodialysis (HEMO) trial, a randomized trial to determine whether increasing urea removal to the maximum practical degree through a 3-times-a-week schedule, showed no difference in mortality in the treatment and control groups. Investigators speculated that the increment in functional waste removal in the HEMO study was too small to produce improvements in mortality. To test this hypothesis, the NIDDK funded the Frequent Hemodialysis Network, a consortium of centers testing whether patients randomized to intensive dialysis would demonstrate improved (reduced) left ventricular LV mass and quality of life. The trial has two arms: the daily (in-center) and the home (nocturnal) arms. Each arm has patients randomized to conventional dialysis or 6 days (or nights) of dialysis. The results of the HEMO trial will be reported in the fall of 2010.

Fig. 1

Expected survival of a 55-year-old person. Data from USRDS in 2009 (ref 1).

Fig. 2

Comparison of estimated GFR values in dialysis and normal patients. GFR values for dialysis patients are computed by extrapolating urea removal rates over time. Kt/V values are computed from urea kinetic measurements and are estimates of urea removal during a single dialysis session. The lower value of Kt/V (1.1) is typical for conventional treatment. The higher value (1.5) was the target for more intensive dialysis using a thrice weekly schedule in the HEMO trial.

Fig. 3

Design of the Frequent Hemodialysis Network (FHN) trial. Dialysis in the nocturnal arm was conducted at home; dialysis in the daily arm was conducted in dialysis centers. Conventional dialysis was always given 3 times a week. Frequent dialysis was targeted for 6 times a week. The duration of the dialysis in the nocturnal arm was much longer than the duration in the daily arm.

Fig. 4

Effect of nocturnal and conventional home dialysis on left ventricular mass. Patients on nocturnal dialysis for 6 months had a reduction in LV mass while those on conventional dialysis did not. Data from ref (20).