Dialysis: More May Be Better But It's Not That Simple -- Of Course

Jeffrey S. Berns, MD


December 28, 2010

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Hello. This is Dr. Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia. I'm Editor-in-Chief of Medscape Nephrology. I hope everybody had a great time at the American Society of Nephrology annual meeting in Denver. I want to talk briefly this morning about the recent paper[1] that came out in The New England Journal of Medicine from the Frequent Hemodialysis Network Trial Group -- a very interesting paper. It's a difficult study to do, but it compared in-center dialysis 6 times/week with the more conventional in-center dialysis 3 times/week. The study went on for many years because of the difficulty in recruiting patients, but they were able to get about 120-125 patients in each group with follow-up for 12 months. As might be expected, the 6 times/week dialysis group had somewhat less adherence to dialysis treatments than the 3 times/week group, and only received, on average, around 5 or so treatments/week. Nonetheless, their weekly Kt/V was significantly higher than that in the 3 times/week group. Hopefully, many of you have read the paper and already know the results, which showed that there was 30%-40% reduction in the occurrence of 2 coprimary composite endpoints. Both included death. One included a physical functions test and the other included left ventricular mass as assessed by cardiac magnetic resonance imaging. Both of these endpoints were reduced. There weren't enough patients included in the trial to be able to use death as the primary single endpoint, so they used these composites instead. In addition to a significant reduction in these endpoint occurrences, there was substantial and statistically significant improvement in control of hypertension and hyperphosphatemia. There was no improvement in other measures, such as depression, cognitive function, serum albumin level, or use of erythropoiesis-stimulating agents. Improvements in some of these outcomes, though, came at the expense of greater problems related to hemodialysis access, which is probably not a surprise. It wasn't spelled out in the paper whether or not, or to what extent, the buttonhole cannulation technique was used for dialysis access. We don't know whether that would have made a difference or not, but it's certainly something worth exploring. So, is 6 times/week dialysis the way we should go?

There are certainly some clinical improvements that come as a result of more frequent dialysis. The dialysis treatments were short, and one wonders whether we would get even further improvement with more frequent dialysis but of a longer duration. This clinical improvement did come at the expense of greater vascular access problems. So we have to wait and see whether the patient perspective on this favors more frequent dialysis or whether the cost, inconvenience, and difficulty of having to deal with the access complications are going to negate some of the benefit. I look forward to further studies on this, including the companion trial on nocturnal dialysis. My own opinion, which I have expressed here before, is that our conventional 3 times/week 3- to 4-hour dialysis, regardless of what the Kt/V says, is simply inadequate dialysis for many patients -- probably adequate for some, but I think inadequate for many, if not most, of our patients. We'll see what this and other studies that are ongoing tell us.

Thank you. If you have any comments, please submit them through the Medscape video blog site. Have a happy holiday, everybody. This is Jeffrey Berns from the University of Pennsylvania School of Medicine.