Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline.
BACKGROUND
In 2006, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) published clinical practice guidelines for hemodialysis adequacy. Recent studies evaluating hemodialysis adequacy as determined by initiation timing, frequency, duration, and membrane type and prompted an update to the guideline.


METHODS
Systematic review and evidence synthesis.


METHODS
Patients with advanced chronic kidney disease receiving hemodialysis.


METHODS
We screened publications from 2000 to March 2014, systematic reviews, and references and consulted the NKF-KDOQI Hemodialysis Adequacy Work Group members. We included randomized or controlled clinical trials in patients undergoing long-term hemodialysis if they reported outcomes of interest.


METHODS
Early versus late dialysis therapy initiation; more frequent (>3 times a week) or longer duration (>4.5 hours) compared to conventional hemodialysis; low- versus high-flux dialyzer membranes.


RESULTS
All-cause and cardiovascular mortality, myocardial infarction, stroke, hospitalizations, quality of life, depression or cognitive function scores, blood pressure, number of antihypertensive medications, left ventricular mass, interdialytic weight gain, and harms or complications related to vascular access or the process of dialysis.


RESULTS
We included 32 articles reporting on 19 trials. Moderate-quality evidence indicated that earlier dialysis therapy initiation (at estimated creatinine clearance [eClcr] of 10-14mL/min) did not reduce mortality compared to later initiation (eClcr of 5-7mL/min). More than thrice-weekly hemodialysis and extended-length hemodialysis during a short follow-up did not improve clinical outcomes compared to conventional hemodialysis and resulted in a greater number of vascular access procedures (very low-quality evidence). Hemodialysis using high-flux membranes did not reduce all-cause mortality, but reduced cardiovascular mortality compared to hemodialysis using low-flux membranes (moderate-quality evidence).


CONCLUSIONS
Few studies were adequately powered to evaluate mortality. Heterogeneity of study designs and interventions precluded pooling data for most outcomes.


CONCLUSIONS
Limited data indicate that earlier dialysis therapy initiation and more frequent and longer hemodialysis did not improve clinical outcomes compared to conventional hemodialysis.
Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN. Electronic address: yelena.slinin@va.gov.
Yelena
Y
Slinin
Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN.
Nancy
N
Greer
Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN.
Areef
A
Ishani
Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN.
Roderick
R
MacDonald
Department of Medicine, University of Minnesota, Minneapolis, MN.
Carin
C
Olson
Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN.
Indulis
I
Rutks
Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN.
Timothy J
TJ
Wilt
D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000401:mortality; D003863:Depression / Q000453:epidemiology; D061345:Early Medical Intervention; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D009203:Myocardial Infarction / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D011788:Quality of Life; D006435:Renal Dialysis / Q000379:methods*; D020521:Stroke / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome
Hemodialysis (HD); National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI); blood pressure; chronic kidney disease (CKD); clinical outcomes; clinical practice guideline; dialysis frequency; dialysis initiation; dialysis membrane flux; end-stage renal disease (ESRD); hemodialysis adequacy; hemodialysis session duration; systematic review; volume control