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. 2025 Jun;29(6):818-830.
doi: 10.1007/s10157-024-02602-7. Epub 2025 Jan 28.

Longitudinal impact of extended-hours hemodialysis with a liberalized diet on nutritional status and survival outcomes: findings from the LIBERTY cohort

Takahiro Imaizumi #  1   2 , Masaki Okazaki #  1   3 , Manabu Hishida  4 , Shimon Kurasawa  1   3 , Nobuhiro Nishibori  1 , Yoshihiro Nakamura  1 , Shigefumi Ishikawa  1   5 , Katsuhiko Suzuki  1   5 , Yuki Takeda  1   5 , Yuhei Otobe  6 , Toru Kondo  7 , Fumika Kaneda  8 , Hiroshi Kaneda  5 , Shoichi Maruyama  9
Affiliations

Longitudinal impact of extended-hours hemodialysis with a liberalized diet on nutritional status and survival outcomes: findings from the LIBERTY cohort

Takahiro Imaizumi et al. Clin Exp Nephrol. 2025 Jun.

Abstract

Background: Protein-energy wasting (PEW), a unique weight loss linked to nutritional and metabolic abnormalities, is common in patients undergoing hemodialysis (HD) and associated with adverse outcomes. This study investigated whether extended-hours HD combined with a liberalized diet could overcome PEW and improve survival.

Methods: The body mass index (BMI) and survival outcomes in patients undergoing extended-hours HD were evaluated for up to 8 years using data from the LIBeralized diet Extended-houRs hemodialysis Therapy (LIBERTY) cohort. Extended-hours HD was defined as weekly dialysis length ≥ 18 h.

Results: The LIBERTY cohort included 402 patients who initiated extended-hours HD. An increase in the length and frequency of HD sessions was observed over time, with approximately 70% and 20% of patients undergoing extended-hours HD for > 21 h/week and > 3 sessions/week at 5 years, respectively. The BMI and percentage creatinine generation rate were maintained over time, with no substantial increase in the phosphorus and potassium levels. The estimated BMI initially increased, and thereafter plateaued over time in patients with a baseline BMI < 25 kg/m2, whereas it decreased gradually in patients with a baseline BMI ≥ 25 kg/m2 after several years from baseline. Ninety-one patients died, and 108 discontinued extended-hours HD during the median follow-up period of 6.2 years (interquartile range, 3.5-8.0), yielding a 5-year survival rate of 85%.

Conclusions: Extended-hours HD with a liberalized diet may help achieve favorable survival outcomes and maintain nutritional status. Thus, it is a promising treatment option for managing PEW in patients undergoing HD.

Keywords: Extended-hours hemodialysis; Liberalized diet; Longitudinal study; Protein-energy wasting.

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Conflict of interest statement

Declarations. Conflict of interests: The authors have declared that no conflict of interest exists. Ethical approval: This study adhered to the tenets of the Declaration of Helsinki. The study protocol was approved by the ethics committee of the hospital. Informed consent: Written informed consent was obtained from the patients in the aforementioned prospective subset cohorts; however, the requirement for obtaining consent was waived for studies in which patients did not undergo invasive procedures and only anonymized data were obtained electronically.

Figures

Fig. 1
Fig. 1
Longitudinal changes in dialysis conditions. a Weekly duration of dialysis (hours). b Dialysis sessions per week. More than three times including four times weekly, biweekly, and monthly. c Ultrafiltration rate (mL/h/kg). d Blood flow rate (mL/min). Each bar represents a quarterly category for each year up to 8 years. The quarterly categories for continuous variables are derived from the quarter means of each variable. Although the duration of weekly dialysis sessions, the number of sessions per week, and blood flow rate increase gradually, ultrafiltration rate remains largely unchanged
Fig. 2
Fig. 2
Longitudinal changes in nutritional parameters: body mass index and percentage creatinine generation rate. a Body mass index. b Percentage CGR. Each bar or violin plot represents a value or category summarized quarterly for each year up to 8 years. The quarterly categories of body mass index are derived from the quarter means of each variable. The mean values of %CGR are derived from the closest of the two annual measurements. Both parameters are well maintained over time. CGR, creatinine generation rate; BMI, body mass index
Fig. 3
Fig. 3
Longitudinal changes in laboratory parameters and medications in incident cases of extended-hours hemodialysis. a Serum phosphorus. b Serum potassium. c Phosphate binders. d Weekly dose of ESAs. The dose of ESAs represents an EPO-equivalent dose. Each bar represents a quarterly category for each year through 8 years. The quarterly categories for continuous variables are derived from the quarter means of each variable. Quarterly medications are defined as medications administered at least once in each quarter. The levels of phosphorus and potassium are stable and the proportion of ESA-free patients increased over time. The use of phosphate binder remains largely unchanged except initial increase in the first year. ESA, erythropoiesis-stimulating agent; EPO, erythropoietin
Fig. 4
Fig. 4
Estimated trajectories of body mass index and percentage creatinine generation rate stratified according to the initial values of body mass index. a BMI. b %CGR. The trajectories are estimated using a mixed-effects model with an unstructured variance–covariance matrix, adjusted for baseline age, sex, DM, and the duration of conventional dialysis, stratified according to the category of the baseline values of BMI: < 18.5; 18.5 to < 22; 22 to < 25; and ≥ 25 kg/m2. BMI is well preserved in patients with normal to subnormal baseline levels. The %CGR values increase over time regardless of the BMI category. The values increase even in patients with the lowest category of BMI. BMI, body mass index; CGR, creatinine generation rate; DM, diabetes mellitus
Fig. 5
Fig. 5
Overall survival. a Overall survival in all patients. Five-year survival is 0.85. b Age- and sex-adjusted overall survival, stratified according to the duration of conventional dialysis
Fig. 6
Fig. 6
Graphical overview of the present study
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References

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