In-center nocturnal hemodialysis (INHD) may be an effective way to improve patients’ health-related quality of life (HRQOL), particularly for those who struggle with poor mental health, according to recent study findings published in the Journal of Nephrology.
The modality also has the potential to decrease pill burden and improve phosphate control, according to investigators.
Researchers at the University of Calgary in Alberta, Canada, collected data on 36 patients converting from conventional HD to INHD from October 2013 to January 2015. At baseline, the researchers recorded demographics, medication lists, and laboratory data. Following conversion from HD to INHD, the study participants completed Kidney Disease Quality of Life-36 (KDQOL-36) surveys at baseline and again at 12 months. The KDQOL-36 has 5 domains: SF-12 Mental Component Score (MCS), SF-12 Physical Component Score (PCS); Burden of Kidney Disease; Effects of Kidney Disease; and Symptoms/Problems of Kidney Disease.
All participants were approached to enter the study approximately 3 months after starting nocturnal dialysis. The patients had a mean age of 54 years, and 26 (69.4%) were male. Of the 36 patients, 7 withdrew and 5 declined follow-up.
Overall, MCS increased by 7.1 points to a value of 51.0 after 12 months. Among patients with baseline scores below the median, they observed improvements in Symptoms/Problems of Kidney Disease (+ 15.2), Effects of Kidney Disease (+ 16.9), PCS (+ 9.4) and MCS (+ 10.7).
“What was most novel and surprising is that patients who had the lowest quality of life were, in fact, the ones with most to gain, with significant improvement in 4 out of 5 domains of the KDQOL-36 health related quality of life after transition to in-center nocturnal dialysis,” said study investigator Jennifer MacRae, MD, associate professor of medicine with Cumming School of Medicine at the University of Calgary and medical director for home dialysis at Alberta Kidney Care South in Calgary.
The mean number of blood pressure medications declined significantly from 1.90 at baseline to 0.9 at 12 months. During that time frame, the mean doses of calcium-based phosphate binders decreased from 2.10 to 0.17 g/d. The study also revealed significant improvements in mean pre-dialysis phosphate levels (from 1.90 to 1.13 mmol/L) and calcium levels (from 2.43 to 2.32 mmol/L).
Significant Barriers to Implementation
The most significant barriers to setting up an INHD program relate to logistics, according to Dr MacRae. Major hurdles include dialysis unit capacity and recruitment of staff to cover nocturnal shifts. “Addressing staff concerns about the safety of doing dialysis at night with the lower staffing ratio, and the implementation of an additional 8 hours of dialysis, is often challenging to fit into a dialysis unit that is already at maximum capacity with tight turnaround times,” Dr MacRae said.
There was very high patient turnover within 3 months of initiating INHD in this study (24 exited the program out of 76 who entered). The biggest reason for quitting was difficulty sleeping (50% of the early exits). Those issues can be managed, however. “Given time, with a well-established program, these issues do not represent significant barriers,” Dr MacRae said.
Based on these new findings, she said, INHD should be offered to anyone who is currently attending an HD center and struggling with poor mental health. INHD also should be offered to anyone who wishes to pursue home dialysis, but cannot do so because of technical or logistic issues.
Target Those with Lowest HRQOL
“The patients who derive the most benefit from in-center nocturnal dialysis are those who currently suffer from the lowest HRQOL (with scores below the median). Doctors should target these patients to join an in-center nocturnal dialysis program,” Dr MacRae said.
The study’s main limitation was the lack of a control arm. In addition, the findings may not be generalizable to other centers because the patients in this study were younger than the usual HD patient.
Robert P. Pauly, MD, professor of medicine in division of nephrology at the University of Alberta said INHD is an underused dialysis modality that offers some important incremental benefits over and above conventional thrice-weekly HD. The new findings need be viewed with caution, however. “The current study adds to this body of work. Unfortunately, most of these studies, this one included, have no control group, thus raising the question of systematic bias in outcomes based on the selection of participants in the first place,” Dr Pauly said.
This limitation aside, the fact that this study demonstrates an improvement in HRQOL parameters should not be ignored and should prompt further investigation since so few interventions in nephrology actually make people feel better, according to Dr Pauly.
INHD could easily be scaled from an operational perspective. Dialysis units around the world sit empty all night long. Using these dialysis units night and day could help both the patients and the centers. “In the setting of rising health care costs with ever increasing patient numbers, it becomes inevitable that providers look to utilizing idle resources during the night. And if they do, we might actually be doing something helpful for both the patients and the [health care] system,” Dr Pauly said.
Nephrologist Fredric O. Finkelstein, MD, clinical professor of medicine at Yale University Medical School in New Haven, Connecticut, said clinicians need to consider the impact of the treatment itself on the patient and their caregivers when assessing the benefits of more frequent and/or nocturnal HD. “The dropout rate in the initial months of therapy was quite high,” Dr Finkelstein said. “Thus, one needs to wonder to what extent the improvement in HRQOL noted is a self-selecting process. Those doing poorly drop-out and those doing well continue with the treatment.”
The current study underscores the issue that nocturnal and/or more frequent HD can improve the HRQOL of patients with ESKD and that patients and their caregivers need to be counseled on the potential advantages and benefits, he said.
Dumaine CS, Ravani P, Parmar MK, et al. In-center nocturnal hemodialysis improves health-related quality of life for patients with end-stage renal disease. J Nephrol. Published online May 29, 2021. doi:10.1007/s40620-021-01066-2