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Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients. La hemodiálisis domiciliaria (HDD) con monitores de bajo flujo de líquido de diálisis ha ganado popularidad en los últimos años gracias a su sencillez de diseño, portabilidad y capacidad de desplazamiento. No obstante, existen dudas respecto a la adecuación que este tipo de técnica ofrece, pues utiliza monitores con baño a flujos bajos y lactato. El objetivo de este estudio fue demostrar los beneficios clínicos de la HDD con el monitor NxStage System One® introducido recientemente en España. Presentamos los resultados de un estudio observacional, retrospectivo que incluyó de manera no seleccionada a los primeros pacientes con HDD corta mediante este monitor en 12 centros en España. Se analizó la evolución clínica de 86 pacientes a 0, 6 y 12 meses, incluyendo datos relacionados con la prescripción, evolución de parámetros analíticos de dosis de diálisis, anemia, metabolismo óseo-mineral, evolución de la diuresis residual, utilización de fármacos y datos relacionados con permanencia en la técnica, y causas de salida a lo largo del seguimiento. Pudimos demostrar que este monitor proporcionó una adecuada dosis de diálisis, con tasa óptima de ultrafiltración, con mejoría de los principales marcadores bioquímicos de adecuación en diálisis. El uso de esta técnica se asoció con una disminución de antihipertensivos, captores del fósforo y agentes eritropoyéticos, observándose, además, muy buenos resultados de supervivencia tanto del paciente como de la técnica. La sencillez de este monitor unida a sus buenos resultados clínicos debería facilitar el crecimiento y utilización de la HDD, tanto en pacientes incidentes como prevalentes.

Resumen La hemodialisis domiciliaria (HDD) con monitores de bajo flujo de liquido de dialisis ha ganado popularidad en los ultimos anos gracias a su sencillez de diseno, portabilidad y capacidad de desplazamiento. No obstante, existen dudas respecto a la adecuacion que este tipo de tecnica ofrece, pues utiliza monitores con bano a flujos bajos y lactato. El objetivo de este estudio fue demostrar los beneficios clinicos de la HDD con el monitor NxStage System One® introducido recientemente en Espana. Presentamos los resultados de un estudio observacional, retrospectivo que incluyo de manera no seleccionada a los primeros pacientes con HDD corta mediante este monitor en 12 centros en Espana. Se analizo la evolucion clinica de 86 pacientes a 0, 6 y 12 meses, incluyendo datos relacionados con la prescripcion, evolucion de parametros analiticos de dosis de dialisis, anemia, metabolismo oseo-mineral, evolucion de la diuresis residual, utilizacion de farmacos y datos relacionados con permanencia en la tecnica, y causas de salida a lo largo del seguimiento. Pudimos demostrar que este monitor proporciono una adecuada dosis de dialisis, con tasa optima de ultrafiltracion, con mejoria de los principales marcadores bioquimicos de adecuacion en dialisis. El uso de esta tecnica se asocio con una disminucion de antihipertensivos, captores del fosforo y agentes eritropoyeticos, observandose, ademas, muy buenos resultados de supervivencia tanto del paciente como de la tecnica. La sencillez de este monitor unida a sus buenos resultados clinicos deberia facilitar el crecimiento y utilizacion de la HDD, tanto en pacientes incidentes como prevalentes.

Pulmonary hypertension (PH) defined as a mean pulmonary arterial pressure ≥25 mmHg is a common complication in hemodialysis occurring in up to 58% of patients. PH is classified according to its etiology. We report in a patient with severe PH of mixed etiology (connective tissue disease and left-sided heart failure) who improved after initiation of intensive home hemodialysis. We postulated that the use of a frequent mode of hemodialysis may ameliorate PH via enhanced volume control. Thereby, an intensive hemodialysis schedule may be preferred renal replacement modality in this patient population.

Current guidelines for dialysis specify a minimum Kt/V. For haemodialysis (HD) patients, minimum treatment time and frequency is also specified. The guidelines allow for modification to take account of renal function. The guidelines are not specifically aimed at the elderly and may not be appropriate for all patients in this group. Increasing age is accompanied by physiological and pathological changes that may modify the patient's response to uraemia and dialysis. Frailty and multi-morbidity are likely, but to a variable extent. Elderly patients could be more susceptible to the effects of uraemia and require a higher dose of dialysis. Conversely, the generation rate of uraemic toxins is lower in elderly patients, potentially reducing the need for dialysis. In the elderly, quality of life may be more adversely affected by multimorbidity than uraemic symptoms, thus the dose of dialysis may be less relevant. Higher doses of dialysis may be more difficult to achieve in the elderly and may be less well tolerated. We conclude that the prescription of dialysis in the elderly should be individualized, taking multiple factors into account. An individualized Kt/V may be useful in controlling dialysis dose and detecting problems in delivery. However, achievement of a specified Kt/V may not result in any benefit to an elderly patient and could be counterproductive.

Background Previous US studies have indicated that haemodialysis with ≥6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients. Methods We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association–European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5–4 h/treatment), EHD (three times weekly, ≥6 h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders. Results From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.1 ± 0.8 h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 ± 0.2 h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62–0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71–0.90)]. Conclusions EHD is associated with better survival in European patients treated with haemodialysis three times weekly.

Introduction: Cardiovascular diseases are considered the major cause of death in dialysis patients with end-stage renal disease (ESRD). Recently, intensive hemodialysis has increasingly used and replaced conventional hemodialysis. The present study aimed to evaluate the effect of intensive hemodialysis on LVH regression and blood pressure control. Methods: The present study is self-control, pre- and post-intervention clinical trial on hemodialysis ESRD patients with hypertension (52.5% female with a mean age of 55.55 ± 12.96), who were admitted to Imam Khomeini Hospitals, Golestan Ahvaz in 1396. All patients underwent intensive hemodialysis treatment 4 times a week for 2 months. 2-D color Doppler echocardiography was performed for all patients before the intervention and following 2 months of intensive hemodialysis. The results of chest echocardiographic were used to determine left ventricular thickness. Results: In this study, 40 patients with hypertension were studied. The results of this study showed a significant decrease (P < 0.0001) in the levels of LVH, SBP, DBP and mean BP after intervention in ESRD patients. The level of LVH was decreased from 15.42 ± 1.67 mmHg to 13.86 ± 1.39 mmHg, SBP from 161.50 ± 12.16 mmHg to 141.12 ± 8.87 mmHg, DBP from 25.25 ± 5.15 mmHg to 81/75 ± 2.89 mmHg, and mean BP from 114.66 ± 6.82 mmHg to 101/54 ± 3.98 mmHg. Conclusion: Based on the results, it can be concluded that intensive hemodialysis resulted in improved LVH regression and blood pressure control, and fewer requirements for blood pressure-lowering medications.

(English abstract at the end) La disponibilité en France, durant la dernière décennie, de moniteurs d’hémodialyse à bas débit de dialysat, spécifiquement adaptés pour la dialyse quotidienne (5 à 6 séances par semaine), est contemporaine d’un véritable renouveau de l’hémodialyse à domicile. Si les bénéfices cliniques de l’hémodialyse quotidienne à haut débit de dialysat et de l’hémodialyse longue nocturne trihebdomadaire, qui sont deux modalités d’hémodialyse intensive, ont bien été démontrés, ils le sont beaucoup moins en ce qui concerne l’hémodialyse à bas débit de dialysat. Ainsi certains patients pourraient-ils encore souhaiter utiliser des moniteurs classiques d’hémodialyse afin de pouvoir restreindre le nombre de séances (et donc de ponctions de l’abord vasculaire) à 3 par semaine (ou à 1 jour sur 2) ou bénéficier d’une modalité d’hémodialyse intensive. Abstract The availability in France, for the last decade, of low dialysate flow rate hemodialysis monitors, specifically adapted for daily hemodialysis (5 to 6 sessions per week), is contemporary with a real renewal of home hemodialysis. The clinical benefits of daily hemodialysis with high dialysate flow and of thrice-weekly long nocturnal hemodialysis, which are two intensive hemodialysis modalities, have been demonstrated ; however they are less well demonstrated with low dialysate flow hemodialysis. Thus, some patients may still wish to use conventional hemodialysis monitors in order to limit the number of sessions (and therefore the number of vascular punctures) to 3 per week (or every other day) or wish to benefit from a modality of intensive hemodialysis. Cette revue est mise à disposition selon les termes de la Licence Creative Commons Attribution 4.0 International., Bulletin de la Dialyse à Domicile, Vol. 1 No 2 (2018): Bulletin de la Dialyse à Domicile

Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the comparative effectiveness of these modalities is unclear.We had the following aims: (1) to compare the association of mortality and hospitalization in patients undergoing intensive HD, compared with conventional HD or PD and (2) to appraise the methodological quality of the supporting evidence.MEDLINE, Embase, ISI Web of Science, CENTRAL, and nephrology conference abstracts.We included cohort studies with comparator arm, and randomized controlled trials (RCTs) with50% of adult patients (≥18 years) comparing any form of intensive HD (4 sessions/wk or5.5 h/session) with any form of chronic dialysis (PD, HD ≤4 sessions/wk or ≤5.5 h/session), that reported at least 1 predefined outcome (mortality or hospitalization).We used the GRADE approach to systematic reviews and quality appraisal. Two reviewers screened citations and full-text articles, and extracted study-level data independently, with discrepancies resolved by consensus. We pooled effect estimates of randomized and observational studies separately using generic inverse variance with random effects models, and used fixed-effects models when only 2 studies were available for pooling. Predefined subgroups for the intensive HD cohorts were classified by nocturnal versus short daily HD and home versus in-center HD.Twenty-three studies with a total of 70 506 patients were included. Of the observational studies, compared with PD, intensive HD had a significantly lower mortality risk (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.84;The overall quality of evidence was low or very low for critical outcomes. Outcomes such as quality of life, transplantation, and vascular access outcomes were not included in our review.Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD. As the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis. Practice guidelines that promote shared decision-making are likely to be helpful.Au moment de choisir une modalité de dialyse pour le traitement des patients souffrant d’insuffisance rénale, le taux de survie et la durée des hospitalisations sont des critères décisionnels d’une importance cruciale. Pourtant, l’efficacité différentielle de l’hémodialyse (HD) intensive, de l’HD conventionnelle et de la dialyse péritonéale (DP) demeure à ce jour mal connue.Nos objectifs allaient comme suit : 1) comparer le taux de mortalité et la durée des hospitalisations associés à chacune des modalités (HD intensive, HD conventionnelle et DP), et 2) évaluer la qualité méthodologique des données venant appuyer les résultats.Les données proviennent des bases de données en ligne MEDLINE, EMBASE et ISI Web of Science, de même que de CENTRAL et de résumés de conférence en néphrologie.Ont été incluses à cette méta-analyse les études de cohorte comportant un volet comparatif et les essais contrôlés à répartition aléatoire comptant plus de 50 % de patients adultes et comparant n’importe quelle forme d’HD intensive (plus de 4 séances par semaine ou plus de 5,5 heures par séance) à n’importe quelle forme de dialyse chronique (DP ou HD à raison de 4 séances maximum par semaine ou de 5,5 heures maximum par séance). Les études retenues devaient également rapporter au moins un des deux critères décisionnels prédéfinis (mortalité et hospitalisation).Nous avons employé l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Cette approche s’applique aux revues systématiques et à l’évaluation de la qualité des données. Deux personnes ont passé en revue des citations et des articles complets pour en extraire les données relatives à l’étude. Les divergences ont été résolues par consensus. Nous avons regroupé les différentes mesures provenant des essais à répartition aléatoire et des études observationnelles pour ensuite les analyser, de façon isolée, à l’aide de la méthode générique de l’inverse de la variance avec modèles à effet aléatoire. Pour les données où seules deux études étaient disponibles pour le regroupement des données, nous avons plutôt employé la méthode générique de l’inverse de la variance avec modèles à effet fixe. Des sous-groupes avaient été prédéfinis dans les cohortes de patients traités par HD intensive, selon le moment (de jour ou de nuit) et le lieu (en centre de dialyse ou à domicile) du traitement.Cette méta-analyse compte 23 études totalisant 70 506 patients. Selon les études observationnelles, lorsque comparée à la DP, l’HD intensive était corrélée à un risque de mortalité significativement plus faible (HR=0,67; IC 95 0,53-0,84; IDans l’ensemble, la qualité des données recueillies pour appuyer les critères décisionnels jugés essentiels s’est avérée faible ou très faible. De plus, des éléments tels que la qualité de vie du patient, la greffe et les enjeux liés à l’accès vasculaire n’ont pas été pris en compte dans notre revue systématique.Le traitement de l’insuffisance rénale par HD intensive pourrait être associé à un taux de mortalité réduit et à des séjours à l’hôpital écourtés en comparaison avec les traitements par HD conventionnelle ou par DP. Cependant, en raison de la piètre qualité des données appuyant ces résultats, les patients qui accordent une grande importance à la survie devraient être adéquatement informés et conseillés sur les risques et les bienfaits offerts par l’HD intensive comme modalité de traitement. L’application de lignes directrices concernant la prise de décision conjointe en pratique clinique pourrait être pertinente.

Most of chronic renal disease patients receive 4-h hemodialysis (HD) sessions thrice a week. This is the minimum therapy needed to maintain life. This conventional HD therapy protocol is, however, inadequate to prevent dialysis-related complications. On the other hand, some intensive HD therapies, such as "short daily dialysis," "quotidian dialysis," etc., are being adopted in some dialysis institutions for maximizing the beneficial effects of HD on the quality of life/activities of daily living of the patients. In this paper, the effects of dialysis treatment time and frequency on the adequacy of solute removal in these intensive HD therapies protocols were examined by kinetic modeling using a 1-compartment model. In this model, it is presupposed that urea is distributed throughout the total body fluid compartment and β2-microglobulin (β2-MG) is distributed throughout the extracellular compartment. The time-averaged concentrations (TACs) of BUN and β2-MG can be estimated by inputting the body weight, generation rate of the solute, dialyzer clearance for the solute, and the dialysis treatment time and frequency into the model. According to the results, the TACs were strongly dependent on the total dialysis time per week (T) value and to a slightly lesser degree on the dialysis frequency per week (N) value for both solutes. It is concluded that the 1-compartment model introduced in this study is valid for estimating the TACs of BUN and β2-MG in patients undergoing maintenance HD therapy, and T and N values are important factors influencing the adequacy of solute removal in patients receiving maintenance HD therapy.

Prescribing a regimen that provides "optimal dialysis" to patients who wish to dialyze at home is of major importance, yet there is substantial variation in how home hemodialysis (HD) is prescribed. Geographic location, patient health status and clinical goals, and patient lifestyle and preferences all influence the selection of a prescription for a particular patient-there is no single prescription that provides optimal therapy for all patients, and careful weighing of potential benefit and burden is required for long-term success. This article describes how home HD prescribing patterns have changed over time and provides examples of commonly used home HD prescriptions. In addition, associated clinical outcomes and adequacy parameters as well as criteria for identifying which patients may benefit most from these diverse prescriptions are also presented.

As fertility tends to decline as young women approach end-stage kidney disease (ESKD), pregnancy in this patient population is infrequent. When pregnancy occurs, it is anxiety provoking for managing clinicians as there is a paucity of data to guide timing of the initiation of renal replacement therapy. Once hemodialysis is initiated, best evidence suggests intensive hemodialysis results in better maternal and fetal outcomes. This case vignette reviews fertility issues in women with advanced chronic kidney disease (CKD), maternal and fetal risks associated with pregnancies in this at-risk patient population as well as a management strategy for the delivery of hemodialysis during pregnancy.

In this issue of the Clinical Journal of the American Society of Nephrology , Kalim et al. ([1][1]) report that extending the duration of in-center hemodialysis had little effect on the plasma levels of small solutes. They used mass spectrometry to compare solute levels over 1 year in 20 patients

Our contemporary paradigms of nocturnal and short-daily hemodialysis (NHD and SDHD) have their origins in the earliest era of dialysis care for end-stage renal disease. However, these therapies have received considerably more attention in recent years owing to an increasing body of literature, suggesting a myriad of benefits attributable to these intensive dialysis regimens compared with conventional thrice-weekly hemodialysis. Analyses suggest a survival benefit for NHD and SDHD versus traditional hemodialysis prescriptions, and it is in this context that survival comparisons between intensive dialysis and transplantation must be considered. This literature and its limitations are reviewed here.

Background: Pregnancy in patients on chronic hemodialysis therapy, though unlikely, does happen rarely. Intensive hemodialysis is thought to offer a better survival advantage to the unborn child. Circulating angiogenic factors are helpful for prognostication of pregnant patients with chronic kidney disease who are not on dialysis. Data on their utilization in dialysis patients, however, are limited. Case Presentation: We report the case of a patient with a history of interstitial nephritis who had a kidney transplant that failed after 8 years due to membranous nephropathy. She was initiated on hemodialysis three sessions per week and conceived after being on dialysis for 6 weeks. She was switched to intensive hemodialysis at 8 weeks of gestation and had a C-section because of hypertension at 35 weeks, with delivery of a healthy girl weighing 2012 g. Serum angiogenic factors (placental growth factor and soluble fms-like tyrosine kinase) were measured at 32, 33, and 34 weeks of gestation and at 1, 2, and 3 weeks postpartum. Serum angiogenic factors were similar to what has been reported for patients with chronic kidney disease and were not consistent with preeclampsia. Conclusions: Our case report expands on the literature regarding intensive hemodialysis and angiogenic factor utilization in pregnant dialysis patients. Our case report suggests that starting intensive dialysis early in pregnancy is safe and concentration of angiogenic factors are similar to those reported for patients without kidney disease, except for PIGF levels, which are somewhat higher.

Interest in intensified hemodialysis (HD) regimens is increasing internationally, as there is growing evidence that they are associated with improved outcomes. Appreciation that conventional hemodialysis (CHD), delivered as 4-hour sessions three times a week, is not providing optimal physiological replacement of renal function has led to the development of intensified dialysis therapies. These include long intermittent hemodialysis typically lasting 6-8 hours and delivered three times a week, short daily hemodialysis, providing more frequent sessions 4-7 days a week lasting 2-3.5 hours, and nocturnal hemodialysis, performed 5-7 days a week for 6-8 hours. Studies evaluating outcomes from these programs have indicated superior results to those achieved with CHD, including favorable modifications of cardiovascular risk factors and improvements in a variety of clinical measures. The objective of this review is to present available evidence supporting the hypothesis that in an attempt to provide a "more normal physiology," intensified HD regimens achieve outcomes superior to those historically achieved with CHD.

Most dialysis patients would choose to receive a kidney transplant if possible. However, some patients who are receiving intensive hemodialysis (HD) have opted against transplantation and have chosen to remain on dialysis. In this paper, we examine studies that help to inform the decision between receiving a kidney transplant and remaining on intensive HD. There are no randomized trials directly comparing transplant to intensive HD. Database and prospective nonrandomized studies support a number of conclusions. First, compared to conventional HD, survival appears to be better with either transplantation or intensive HD. Survival appears to be similar between intensive HD and deceased donor kidney transplantation, but the best survival is reported with live donor transplantation. Secondly, people with a kidney transplant or receiving intensive HD report a higher quality of life than people on conventional HD. There is insufficient evidence to determine whether there are significant quality of life differences between these treatments. Finally, the costs of intensive HD compare favorably to those of conventional HD. Renal transplantation is more costly in the first year, but after about 2 years should be less costly than any form of HD. Based on these studies eligible intensive HD patients should be encouraged to pursue transplantation, especially live kidney donor transplantation. Individual concerns about the relative risks and benefits of renal transplantation may drive some patients to choose to stay on dialysis. Clinicians should explore the reasons behind such a decision to ensure that the patient is properly informed; however, appropriately reasoned decisions should be respected.

Clinical outcomes have not improved substantially for patients treated with conventional thrice weekly hemodialysis. More intensive hemodialysis regimens, including daily short dialysis, and nocturnal prolonged dialysis show promise to improve morbidity and mortality. Published studies and trials underway examining these therapies are reviewed.

Cardiovascular mortality remains the leading cause of death in patients with end-stage renal disease. Frequent home hemodialysis in the form of short daily hemodialysis and nocturnal home hemodialysis has been suggested to correct multiple cardiovascular surrogate endpoints in observational and randomized controlled studies. This review discusses recent advances of intensive hemodialysis on important cardiovascular outcomes including blood pressure control and cardiovascular geometry and function. Its impact on calcium-phosphate metabolism and anemia management as they relate to cardiovascular outcomes are highlighted.

症例は67歳，女性．IgA腎症による慢性腎不全で，全身浮腫を認めたため透析に導入．透析は特に問題なく施行できたが，著明な心拡大を認め，心エコーにて左室駆出率の低下（24％）と中等量の心嚢水貯留と右房のcollapse所見を認め，心タンポナーデの状態と診断．原因疾患の検索では特に異常所見は得られず，まずは連日透析と徹底した16 kgに及ぶ除水を行った．しかし，心拡大や心エコー所見は軽度の改善に止まったため，心嚢穿刺を敢行し，約500 mLの粘稠性で非血性の滲出液を排出した．心嚢液からは菌の検出はなく，その後の持続ドレナージは施行しなかったが，心拡大は速やかに軽快し，心エコー所見も改善した．尿毒症性心外膜炎は，近年経験することがまれになってきたが，致死的な疾患としての認識が必要な疾患である．今回われわれの経験した症例は，循環動態が安定していたため，まず連日の強化透析を行い大量の除水も行ったが，それだけでは大きな改善が得られず，その後1回の心嚢穿刺排液したのみで著明な改善を認めるに至り，このような症例における対応への一つの示唆を与える症例であった．

More frequent and intensive hemodialysis (HD) schedules continue to garner interest internationally. Two dominant regimens have emerged, namely short-daily and nocturnal HD. A growing body of observational data suggests that these regimens allow more rigorous control of biochemical and physical parameters when compared with conventional HD. This review describes the methodology used in providing more frequent or sustained HD both in center and at home, and attempts to provide a physiological rationale for the practices described in the current literature.

Background Uremic neuropathy is a common complication in patients with end stage kidney disease. Its pathogenesis has been attributed to accumulation of uremic toxins. Kidney transplantation has been the best therapeutic option. Case presentation We describe a case of severe uremic peripheral neuropathy, which improved after conversion from a conventional renal replacement therapy to nocturnal hemodialysis. Conclusion Enhanced uremic control by intensive hemodialysis may contribute at least in part to clinical and neurophysiological improvements of uremic neuropathy.

Home haemodialysis (HHD) is undergoing a significant revival. There is a global demographic shift with a rising mean age of dialysis patients. We postulated that intensive HHD may also benefit the older dialysis population. However, there is a lack of literature on the feasibility of HHD in older patients with end-stage renal disease (ESRD). The purpose of this study was to ascertain the feasibility of delivering HHD to older patients.We conducted a multi-centre multinational retrospective cohort study of HHD patients a parts per thousand yen65 years of age at the time of HHD initiation; 79 patients were included. Baseline demographic data included age at start of dialysis, race and sex. Dialysis characteristics including total weekly treatment hours, need for assistance, training time, dialysis access, modality and dialysis vintage were captured, as well as cause of ESRD and medical co-morbidities. The primary outcome was time to technique failure or death. Rates of hospitalization, cardiovascular events, non-infectious vascular access events and infections were collected.Median age at start was 68 (interquartile range 66-71) years. An arteriovenous fistula was the predominant access, and most patients were receiving This analysis confirms feasibility of HHD in patients 65 years or older at the start of this modality and should foster further research on the potential benefits of (intensive) HHD in older ESRD patients.

Despite a significant research effort, the optimal dialysis regimen remains a topic of major controversy. There is a growing interest in intensive hemodialysis regimens as they have been associated with positive outcomes in several observational studies. However, recent evidence from a large cohort study casts doubts on the benefits of intensive hemodialysis. In this paper, we review the evidence on this topic and discuss the most recent results in the context of the existing literature to provide a global appraisal of the state of the evidence.

The current interest in intensive hemodialysis (HD) was born out of the impasse in an effort to improve survival and quality of life (QOL) in patients with end-stage renal disease. In this review, we have summarized the emerging data of intensive HD on (i) survival, (ii) cardiovascular outcomes, (iii) phosphate balance and (iv) QOL. Although there is a consistent and compelling signal favoring intensive HD, it is important to balance the enthusiasm with the significant amount of perceived and actual barriers for our patients to overcome to receive or perform intensive HD. For an individual patient, the answer to the question ‘What is the best form of intensive hemodialysis?’ should be a consideration between the benefits sought and the obstacles in attaining intensive HD. In the future, changes in dialysis technology, healthcare delivery and education strategy are needed to allow the majority of patients to receive optimal renal replacement therapy.