Rationale for Daily Hemodialysis

The rational for daily hemodialysis, which has been practiced for more than 30 years, is based on historic considerations, common sense, physiologic knowledge, and clinical research reported on in more than 130 articles, abstracts, and symposia. These clinical studies include more than 300 patients, some of whom were monitored for 20 years. A bibliography of more than 120 articles is included. 1–50,51–100,101–123 Historic Considerations The first few months after invention of the arterio-venous shunt, chronic hemodialysis was performed on vital indications, then once weekly, and then eventually twice and then three times weekly. Every time dialysis frequency was increased there was a great improvement in patient well being. Logical thinking would indicate, then, that further increases in frequency would result in even more improvement; however, that conclusion has only been put into practice by a few pioneers. The startling increase in the number of patients needing treatment perhaps focused the dialyzing physicians on quantity rather than quality. Budgetary constraints and later profit motives became a concern, and finally, when thrice weekly dialysis became established, conservatism, sloth, stupidity, and indifference prevented further improvements. Common Sense Common sense tells us that patients should be dialyzed every day. We treat diseases in an even manner. Hypertension is controlled every hour of the day, yet dialysis patients have their hypertension treated only for a few hours three times a week by fluid removal. People with diabetes receive their insulin during the weekend, yet we let the metabolic abnormalities of uremia and electrolyte imbalances and fluid overload go untreated for 3 days over the weekend. It is clear that patients with end-stage renal failure should also have their disease treated every day. It is performed when they are in the conservative phase with phosphate binders and antihypertensives, yet we dialyze irregularly according to the Old Testament, God rested on the seventh day, and leave them without treatment 4 of the 7 days. The death rate of dialysis patients after the long 3 day dialysis interval, on Mondays and Tuesdays, is twice that of the other weekdays. Renal Physiology The third rationale is consideration of renal physiology. The discussion of dialysis adequacy, particularly in the United States, has focused almost entirely on urea removal or Kt/V. The assumption is that the main function of the kidneys is small toxin removal. Yet the kidneys are not handling urea well, because up to two-thirds of the filtered urea diffuses back in the tubuli. Maintaining homeostasis is the main function of the kidney, not intermittent urea removal, with wild swings in osmolality that result in intracellular water migration and cerebral edema. If one assumes that toxin removal, as modeled by pre- and postdialysis urea removal, is the main effect to be achieved, then K and t become interchangeable in the Kt/V equation, and there are no physiologic considerations. Experience shows that for equivalent Kt/V, short hyper-efficient dialysis has a much higher death rate than long, slow dialysis, and the best results are with daily hemodialysis. It is much more important how one physiologically dialyzes, than how much one dialyzes. Urea was also a poor choice to use as the model for dialysis efficiency. Creatinine is a better model toxin because it is removed only by filtration, the only removal process used by present day hemodialysis, and diffuses back much less than urea. Clearly, short intermittent dialysis schedules, with artificial kidney filters that have creatinine and urea clearances two or three times higher than in the native kidneys, fall far short of simulating renal function. From a mathematical point of view the factors in Kt/V are all independent and exchangeable, but from a physiologic viewpoint they are all independently important in how patients fare. Time is needed for sodium and water removal, and with “isolated ultrafiltration—dry dialysis,” it can be achieved with a K of 0. When providing Kt/V, a very high K causes serious complications, including fatigue, headache, confusion and sometimes, seizures or death. A low V, the result of old age, malnutrition, or intercurrent disease, is more predictable of death than Kt/V, the J-curve. The long dialysis schedules used by the Tassin group are much better, but the best simulation is with short daily and, even more, with long nightly hemodialysis. The intermittence of dialysis, or its unphysiology, is a major cause of ill effects; this has probably become worse as dialysis populations have become older, with more fragile and less resilient cardiac and vascular systems. Older patients do not tolerate well the wild swings in electrolytes and acid-base balance and fast removal of sodium and water, which is the result of the most widely used dialysis scheme in the United States, three times a week for 3.5 hours each time. Physiology is much more important than urea removal. One needs time to get rid of the accumulated sodium and water. Long slow dialysis, which is used in Tassin and by the Japanese, who use a 50% longer dialysis time than in the United States, is an important factor in the superior survivals reported by Dr. Charra and the Japanese Registry. Even when corrected for age and diagnostic differences, the death rate in Japan is only one fourth of that in the United States. However, Japanese patients treated with short dialysis have the same death rate that patients in the United States have. In Tassin, young patients have a survival rate four times better than patients in the United States, and older patients have survival rates 12 times better than in the United States. As the dialysis population has changed, the patients are older, have poor hearts and a rigid vascular system, and do not tolerate fast, hectic dialysis. The great improvement one sees from daily hemodialysis rests on the fact that one basically halves the swings in osmolality, water, and electrolyte abnormalities. The physiology of daily dialysis is twice as good as with intermittent dialysis. Physiology is more important than Kt/V. Clinical Science and Daily Dialysis The final rationale for daily hemodialysis is a clinical experience that spans more than 30 years since DePalma introduced long nightly and short daily dialysis in Los Angeles in 1967. Studies on more than 300 patients from more than 30 centers have been reported in the literature. 1–50,51–100,101–123 Uniformly, clinical experience shows higher hematocrits and less or no use of erythropoietin and transfusions. Patients experienced better blood pressure control with medications: less than one-half of the doses needed for patients on intermittent 3 times per week dialysis; better nutrition and protein intake; much improved dialysis tolerance, a better sense of well being, energy, and absence of fatigue between dialysis; and an overall better quality of life. There is less hospitalization and better rehabilitation. There also seem to be no ill effects on the vascular access, with experience covering thousands of patient-months. Social intrusion is less, because patients do not have the hangover almost uniformly experienced by those on three times weekly hemodialysis. They can bounce out of the dialysis chair and go right to their work. There is no need for lying around and getting chicken soup for postural hypotension, and then go home and sleep because of the postdialysis fatigue. In more than 120 articles 1–50,51–100,101–123 on daily hemodialysis, spanning one-third of a century and involving more than 300 patients, clinical and biochemical parameters, comfort during and between dialysis, and quality of life all improve as patients increase their dialysis frequency. There is no dissenting voice, and almost all studies use the best clinical research protocol, with the patients as their own control subjects. Thus, historic evidence, common sense, considerations of renal physiology, and a fine body of clinical science literature indicate that daily hemodialysis should be the standard, and that the best treatment is done every day with a hemodialysis machine. Understanding of both dialysis and access technology is available to make this realistic for most dialysis patients. The only serious obstacle is the payment policy in the United States. Dialysis is only reimbursed three times weekly. Fine economic analyses indicate that the increased cost for daily dialysis is more than offset by savings in hospitalization and medications, yet the peculiarities of different funds prevent the government from realizing these savings. In these proceedings, the cumulative clinical experience is from North America. Canada is ahead of the United States because there are more patients on daily hemodialysis in Canada than here, despite the fact that Canada has only one-tenth the population of the United States. George Ting, who has the largest and longest sort daily hemodialysis program in North America, reports his excellent results with short in-center daily hemodialysis in seriously ill older dialysis patients. Pierratos, the pioneer of long nightly hemodialysis, updates us on his experience. Lindsay and associates give us the first glimpse of their well designed comparison of short daily and long nightly dialysis; they are using both a crossover and matched control approach. Cacho tells us about some problems of training an inner city population for long nightly home hemodialysis. Robers and Lockridge discuss the economic issues and Hannah discusses the implications for health maintenance organizations. Finally, there are two moving testimonials by patients, both veterans of almost all the treatment modalities available when kidney function is lost. Daily home hemodialysis is matchless!

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