title: Intensive Hemodialysis and Potential Risks With Increasing Treatment.
abstract: Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.
authors: Indiana University Medical School, Indianapolis, IN.
authors: Michael A
authors: MA
authors: Kraus
authors: Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH.
authors: Sheru
authors: S
authors: Kansal
authors: Division of Nephrology, University of British Columbia, Vancouver, Canada.
authors: Michael
authors: M
authors: Copland
authors: Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital Renal Program, Winnipeg, Canada.
authors: Paul
authors: P
authors: Komenda
authors: Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN. Electronic address: wein0205@umn.edu.
authors: Eric D
authors: ED
authors: Weinhandl
authors: American Society of Hypertension Comprehensive Hypertension Center, Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago Medicine, Chicago, IL.
authors: George L
authors: GL
authors: Bakris
authors: Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada.
authors: Christopher T
authors: CT
authors: Chan
authors: Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom.
authors: Richard J
authors: RJ
authors: Fluck
authors: Wake Forest University Medical Center, Winston-Salem, NC.
authors: John M
authors: JM
authors: Burkart
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D002405:Catheterization, Central Venous / Q000009:adverse effects; D006801:Humans; D007239:Infections / Q000209:etiology; D007668:Kidney / Q000503:physiopathology; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006435:Renal Dialysis / Q000009:adverse effects* / Q000379:methods*; D012307:Risk Factors
keywords: Buttonhole cannulation; Frequent Hemodialysis Network; caregiver; chronic kidney disease; daily dialysis; end stage renal disease (ESRD); home dialysis; infection; intensive hemodialysis; mortality; nocturnal hemodialysis; residual renal function; review; short daily hemodialysis; survival; technique failure; vascular access