Monday, November 21, 2011

Frequent Hemodialysis Trials: ASN 2011 update

The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial. This trial was launched because it was noticed from small studies that more frequent nocturnal dialysis may help improve outcomes in dialysis patients. A multicenter study headed by Dr. Rocco et al where 87  patients randomized to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/V(urea).  NO significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) was found. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Sample size was small which could have been a reason of these negative result.

A sister of this trial was conducted: this time it was morning dialysis ( not nocturnal) but daily vs conventional hd on 245 patients. Compared two groups 6times weekly vs 3times weekly. This was an in-center trial. Average delivered 5.2 days vs 2.9 days in the two arms respectively. The time was shorter in the daily so the total hours were only 20% more in the daily arm overall. However patients in the daily arm still did better compared with the conventional group. Both primary outcomes and secondary outcomes were the same as for the nocturnal trial but they were significantly better for the latter(during the day). The reason for the discordance is being investigated.( of note the nightly dialysis received much more time on dialysis than either daily frequent or conventional)
Final note :
"FHN participants were younger and the racial composition for each study was different from the racial composition of the aggregate US dialysis population. Catheters for vascular access were more common in FHN Nocturnal Trial participants."

Post by
Dr. Azzour Hazzan
Hofstra NSLIJ Nephrology

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