Home hemodialysis: Present state of the evidence

Abstract

Given the benefits described, there are subgroups of patients with ESRD that may be particularly good candidates for more intensive hemodialysis. These include: • Patients with poor quality of life on current renal replacement modalities; • Patients who want to work during the daytime; • Patients who need or want to liberalize their diet; •Patients who have disabling intradialytic or interdialytic complications; - Unstable blood pressure during dialysis - Severe cramping during dialysis - Uncontrollable hypertension - Impaired left ventricular function or congestive heart failure - Persistent hyperphosphatemia - Calciphylaxis • Severe sleep apnea; • Patients who wish to stay with a home therapy after transitioning from peritoneal dialysis; • Patients who may not be candidates for kidney transplantation; • Patients who have difficulty in controlling uremic symptoms: - Obese patients - Patients with poor vascular access blood flow. More than these patients, having the ability to tailor a hemodialysis therapy to meet their unique needs may be critically important to ensure good outcomes and better quality of life. More than 100 abstracts and peer-reviewed journal articles have demonstrated clear and consistent benefits of more intensive hemodialysis on numerous biochemical, physical, and psychological functions. This is the case whether the therapy is performed as SDHD or as NHD (although the evidence base is more robust with NHD). These benefits include improvements in cardiovascular outcomes, bone and mineral metabolism, nutrition, sleep, and quality of life. Furthermore, very limited data supports improved hospitalization rates and overall mortality as compared to CHD. At this time, the NIH frequent dialysis study is comparing these more intensive dialysis strategies in a prospective manner. It is critical that properly controlled clinical trials be designed to support conclusions based upon observational or cohort studies. The results of this important trial will provide important comparative information to allow clinicians to offer a wide spectrum of renal replacement therapies to meet the goals of their patients.