More Is Not Always Better: Frequent Dialysis Does Not Markedly Improve Physical Health

More Is Not Always Better: Frequent Dialysis Does Not Markedly Improve Physical Health
Released: 3/9/2012 9:00 AM EST
Embargo expired: 3/15/2012 5:00 PM EDT
Source: American Society of Nephrology (ASN)
Other efforts needed to boost kidney failure patients’ low physical capacity
• Patients with kidney failure have relatively poor physical health.
• Frequent dialysis does not markedly improve kidney failure patients’ overall physical capacity compared with conventional dialysis.
Kidney failure is on the rise and currently afflicts 2 million people worldwide.

Newswise — Washington, DC (March 15, 2012) — Some recent observational studies suggest that more frequent hemodialysis may prolong kidney failure patients’ lives compared with conventional dialysis. If it does, what’s the quality of that extra life? The additional treatments—which are time-consuming and take a considerable toll on patients—do not markedly improve patients’ physical health, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN).
Kidney failure, or end-stage kidney disease, afflicts more than 2 million people worldwide. Many of these individuals are on long-term hemodialysis and suffer from relatively poor physical health.
Researchers and clinicians have wondered whether increasing the frequency of dialysis treatments can improve or at least preserve kidney failure patients’ overall physical capacity by reducing excess body fluid, improving their exercise ability, providing a better balance of nutrition, and preserving muscle mass, among other things.
To test this, Yoshio Hall, MD (University of Washington, Seattle) and his colleagues examined changes in physical health among patients enrolled in two studies: the Frequent Hemodialysis Network Daily and Nocturnal Trials, which randomized patients to receive either frequent (six times per week) or conventional (three times per week) dialysis for one year. All patients in the Daily Trial received treatments in a clinic while nearly all of those in the Nocturnal Trial received them at home, while they slept.
Among the major findings:
• Among the 245 patients in the Daily Trial, patients randomized to frequent compared with conventional dialysis experienced no significant change in physical performance, but they reported that they felt that their physical health and functioning had improved.
• Among the 87 patients in the Nocturnal Trial, patients who received frequent dialysis did not demonstrate better physical performance or report better physical health and functioning compared with patients who received conventional dialysis. Patients in both groups experienced improved physical health and functioning over the course of the year, though, perhaps due to the switch from clinical to home-based treatments.
“Frequent hemodialysis as currently practiced may improve the lives of some but is not a cost-effective or practical solution to improving the physical health of most patients with end-stage kidney disease,” said Dr. Hall. “Faced with rising numbers of persons with progressive chronic kidney disease worldwide, we need to broadly consider innovative strategies beyond manipulating the dose of dialysis to substantially improve or preserve the physical capacity of patients with end-stage kidney disease,” he added.
Study co-authors include Brett Larive (Cleveland Clinic Foundation); Patricia Painter, PhD (University of Utah, Salt Lake City); George Kaysen, MD, PhD (University of California, Davis); Robert Lindsay, MD (University of Western Ontario and London Health Sciences Center, in Canada); Allen Nissenson, MD (DaVita, Inc.); Mark Unruh, MD (University of
Pittsburgh); Michael Rocco, MD (Wake Forest University School of Medicine); Glenn Chertow, MD (Stanford University School of Medicine); and the Frequent Hemodialysis Network Trial Group.
Disclosures: The Frequent Hemodialysis Network trials were supported by the National Institutes of Health (NIH), National Institutes of Diabetes and Digestive and Kidney Diseases, the Centers for Medicare and Medicaid Services, and the NIH Research Foundation. Contributors to the NIH Foundation in support of the Frequent Hemodialysis Network trials included Amgen, Baxter and Dialysis Clinics. Additional support was provided by DaVita, Dialysis Clinics, Fresenius Medical Care, Renal Advantage, Renal Research Institute, and Satellite Healthcare. Dr. Hall has received research support from Satellite Healthcare’s Norman Coplon extramural grant program. Dr. Kaysen has received research support from Dialysis Clinics, Inc. Dr. Nissenson is employed by DaVita, Inc. Dr. Unruh has received research support from Satellite Healthcare’s Norman Coplon extramural grant program, Dialysis Clinics, Inc. and Baxter Healthcare and has consulted for Merck, Sigma-Tau and Baxter Healthcare. Dr. Rocco has consulted for Amgen, Inc. and DaVita, Inc. Dr. Chertow is a member of the Board of Directors of Satellite Healthcare and the Scientific Advisory Board of DaVita, Inc. and has consulted for Amgen, Inc.
The article, entitled “Effects of Six versus Three Times per Week Hemodialysis on Physical Performance, Health, and Functioning: Frequent Hemodialysis Network (FHN) Randomized Trials,” will appear online at on March 15, 2012, doi: 10.2215/CJN.10601011.
The content of these articles does not reflect the views or opinions of The American Society of Nephrology (ASN). Responsibility for the information and views expressed therein lies entirely with the author(s). ASN does not offer medical advice. All content in ASN publications is for informational purposes only, and is not intended to cover all possible uses, directions, precautions, drug interactions, or adverse effects. This content should not be used during a medical emergency or for the diagnosis or treatment of any medical condition. Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

Founded in 1966, and with more than 13,500 members, the American Society of Nephrology (ASN) leads the fight against kidney disease by educating health professionals, sharing new knowledge, advancing research, and advocating the highest quality care for patients.

I wonder if the doctors who wrote the following know they have been corrected:

Results of daily dialysis
“Disappearance of postdialysis fatigue, better dialysis adequacy, a higher removal of middle and large molecules, a reduction of phosphate binders, improvement of status nutritional, and an important reduction of cardiovascular risk factors were observed.”

Dr. Belding Scibner and Dr. Dimitrios Oreopoulos
“Short hemodialysis sessions have great appeal only to the uninformed dialysis patient and to for-profit dialysis centers.”

“By incorporating dialysis frequency, the HDP takes into account the very positive results that have been obtained with more frequent dialysis by De Palma, Buoncristiani, Bonomini, Pierratos, and Lockridge.” (same article as previous quote)

Thanks for posting this, Plugger. I felt strongly enough that the conclusions the ASN reached on the basis of this study were WRONG that I blogged about it on the Nephrology News & Issues site. You can read my response to it here:

LMK what you think!

I liked it so much I put it up on some of the message boards!

Thanks! This is an important story to share. MDs who are not paying attention will think that those headlines (and the ASN article) are accurate, and better dialysis is just a lot of hype. But the benefits of better treatment are very real!

They don’t want to know that anything is any better so that they can just continue the status quo. The FHN is marred by an unrepresentative patient population with unrealistic survival revealing over selection by the FHN trial group. If you take high functioning dialysis patients with about a 7% mortality rate, it is not at all surprising that in a one year period of time, little differences showed up in physical functioning. Take that same group out 5 years and see what the results are. The RCT’s are too short, too highly selected those interpreting the results too biased in my opinion against daily dialysis from prior articles and studies that they have authored.

I DID feel like this was a rather frantic effort to try to support the unsupportable status quo, Peter. We know that only 6% of nephrologists would choose this option if their kidneys failed–but they are doing backflips to make it seem okay. It’s not okay! Minimally, folks need 4 hours of dialysis at a time, every other day. More dialysis feels more like having healthy kidneys. It’s simple common sense. As Carl Kjellstrand likes to say, there is no randomized controlled trial proving that jumping out of an airplane without a parachute will kill you. Some things are obvious.

Agreed, these people simply do not want to change.

Dori, one of the few times that we do totally agree.

As a patient who has experienced both 3 x in unit and now 5 or 6 x pw at home my response is that the conclusions are extremely wide of the mark and support my view as expressed in my response to J Ager greener dialysis comments that the medical renal profession generally seems to prefer the staus quo; it is too common to here the comment “we’ve always done it this way so why should we change” and the view that in dialysis one size (proceedure) fits all - it doesn’t, we are all different and staff could learn a lot from patients if only they would listen, discuss and accept our comments as worthy of consideration
More dialysis has given me better haematollagy and a more active lifestyle

Sounds as if those of us who believe in better dialysis are in violent agreement, David. :slight_smile: