Seven Ways to Know When Dialysis is Optimal (Not Just "Adequate")

If you have been reading our blog (and if not, you may want to go back and peek!), you'll see that we are not fans of Kt/V urea as a measure of dialysis "adequacy." For that matter, we're not fans of the concept of adequacy. Merriam-Webster defines adequate as: "Good enough: of a quality that is good or acceptable: of a quality that is acceptable but not better than acceptable."¹

Gosh, what a ringing endorsement! It makes me want to rush right out and pick up some adequately safe food, buy a car with an adequate safety record, and hire someone to do an adequate job on my taxes. Using this definition, I give "adequate" dialysis a D grade—just above failing.

If I needed dialysis, I would want "better than acceptable"—at least a B (an A would be even better) and bet others would prefer to get better grades of dialysis, too, if they knew. In fact, we know that most nephrologists want better than D grade dialysis. Just 6% of them chose standard in-center HD in our national survey!² If we aim for optimal dialysis, it might look a lot more like this:

1. People feel good shortly after a treatment is over. Most peritoneal dialysis (PD) users have no sharp ups and downs before or after an exchange. The same is not true of most HD. In 2006, Canadian researchers found that the answer to, "How long does it take you to recover from a dialysis session?" is a sensitive, valid, and reliable measure of health-related quality of life in dialysis patients.³ How long ^does it take to recover after standard in-center HD? A new DOPPS paper⁴ found that longer recovery time was linked with higher mortality, and:

   • 10% took longer than 12 hours to recover
   • 17% took 7-12 hours
   • 41% took 2-6 hours
   • 32% had a recovery time of less than 2 hours

   How long does it take to recover from short daily HD? About 30 minutes.³ And for extended (nocturnal) HD? About 10 minutes.³ Clearly, these options are closer to optimal.

2. Water is removed gently and slowly during treatment. Dr. Tom F. Parker III has given some of the best talks I've ever seen at the Annual Dialysis Conference. This year, he noted that rapid fluid removal causes heart damage,⁵ and pointed out a dangerous sequence of events:

   • Higher rates of blood pressure crashes during treatment
   • Cardiac stunning, which may trigger fibrosis in the heart, and left ventricular hypertrophy (LVH); a known killer
   • Not enough blood supply to the brain and internal organs

   Longer treatments are gentler than shorter ones, and cause less myocardial stunning.⁶ A key DOPPS paper found that standard in-center HD treatments that were 4 hours long boosted the chance of survival by 30%—and each extra 30 minutes of treatment adds another 7%.⁷ Removing fluid more often than thrice weekly is also gentler.

3. No blood pressure pills are needed. Optimal dialysis controls blood pressure by itself. Both short ^daily8 and extended (^nocturnal9) HD require few—or no—blood pressure meds. With standard in-center HD, it is common to see people who need two, three, or even four classes of blood pressure meds.
4. Calcium is ONLY where it belongs. Optimal dialysis keeps calcium in the bones and blood, where it should be—not in the blood vessels, soft tissues, joints, or elsewhere.
5. No phosphate binders are needed. Optimal dialysis removes so much phosphorus that binders aren't needed—nor are meal plans that limit whole grains, and other healthy sources of fiber. The standard in-center HD diet can be the polar opposite of a meal plan that will optimize blood glucose levels for those with diabetes (about 50% of the dialysis population). Extended (nocturnal) HD can remove so much phosphorus that some who use it may even need phosphate supplements.¹⁰
6. Nerves are healthy. Diabetes is a known cause of neuropathy. But, too often, non-diabetic people on dialysis develop nerve damage. Healthy nerves in those who don't have diabetes is a sign of optimal dialysis.
7. Good sleep quality. Sleep problems are very common in the general population, and even more so on standard in-center HD¹¹ where not removing enough fluid can contribute to sleep apnea,¹² and melatonin levels go awry.¹³ But, optimal dialysis improves sleep. We see this in short daily HD¹⁴ and extended (nocturnal¹⁵) treatments. More dialysis is better—and it improves sleep. Using a cycler for PD can improve sleep apnea.¹⁶ Nocturnal HD normalizes melatonin levels.¹³ Restless legs syndrome (RLS) and other sleep disorders are four to 20 times as common among those who do standard in-center HD as in the general population—and the presence of RLS predicts higher mortality.¹⁷

If all seven of these factors are present, the chances are good that dialysis is optimal! If not, looking at factors like these can help you sort out what isn't right and how to improve it.

References

1. http://www.merriam-webster.com/dictionary/adequate
2. Merighi J, Schatell DR, Bragg-Gresham JL, Witten B, Mehrotra R. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int. 2012 Apr;16(2):242-51
3. Lindsay RM, Heidenheim PA, Nesrallah G, Garg AX, Suri R. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change. Clin J Am Soc Nephrol. 2006 1:952-959
4. Rayner HC, Zepel L, Fuller DS, Morgenstern H, Karaboyas A, Culleton BF, Mapes DL, Lopes AA, Gillespie BW, Hasegawa T, Saran R, Tentori F, Hecking M, Pisoni RL, Robinson BM. Recovery time, quality of life, and mortality in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis. 2014 Feb 13 [Epub ahead of print]
5. Flythe JE, Kimmel SE, Brunelli S. Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney Int. 2011 Jan;79(2):250-7
6. Jefferies HJ, Virk B, Schiller B, Moran J, McIntyre CW. Frequent hemodialysis schedules are assocated with reduced levels of dialysis-induced cardiac injury (myocardial stunning). Clin J Am Soc Nephrol. 2011. 6:1326-32
7. Saran R, Bragg-Gresham JL, Levin NW, Twardowski ZJ, Wizemann V, Saito A, Kimata N, Gillespie BW, Combe C, Akiba T, Mapes DL, Young EW, Port FK. Longer treatment time and slower ultrafiltration in hemodialysis: Associations with reduced mortality in the DOPPS. Kidney Int. 2006 69:1222-8
8. Lorenzen JM, Thum T, Eisenbach GM, Haller H, Kielstein JT. Conversion from conventional in-centre thrice-weekly haemodialysis to short daily home haemodialysis ameliorates uremia-assocatiated clinical parameters. Int Urol Nephrol. 2012 Jun;44(3):883-90
9. Nesrallah G, Suri R, Moist L, Kortas C, Lindsay RM. Volume control and blood pressure management in patients undergong quotidian hemodialysis. Am J Kidney Dis. 2003 Jul;42(1 Suppl):13-7
10. Pierratos A. Daily (quotidian) nocturnal home hemodialysis: nine years later. Hemodial Int. 2004 Jan 1;8(1):45-50
11. Kutner N, Zhang R, Johansen K, Bliwise D. Associations among nocturnal sleep, daytime intradialytic sleep, and mortality risk in patients on daytime conventional hemodialysis: US Renal Data System special study data. Hemodial Int. 2013 Apr;17(2):223-9
12. Elias RM, Chan CT, Paul N, Motwani SS, Kasai T, Gabriel JM, Spiller N, Bradley TD. Relationship of pharyngeal water content and jugular volume with severity of obstructive sleep apnea in renal failure. Nephrol Dial Transplant 2013 Apr;28(4):937-44
13. Koch BC, Nagtegaal JE, Hagen EC, Wee PM, Kerkhof GA. Different melatonin rhythms and sleep-wake rhythms in patients on peritoneal dialysis, daytime hemodialysis, and nocturnal hemodialysis. Sleep Med. 2010 Mar; 11(3):242-6
14. Jaber BL, Schiller B, Burkart JM, Daoui R, Kraus MA, Lee Y, Miller BW, Teitelbaum I, Williams AW, Finkelstein FO; FREEDOM study group. Impact of short daily hemodialysis on restless legs symptoms and sleep disturbances. Clin J Am Soc Nephrol. 2011 May;6(5):1049-56
15. Beecroft JM, Duffin J, Pierratos A, Chan CT, McFarlane P, Hanley PJ. Decreased chemosensitivity and improvement of sleep apnea by nocturnal hemodialysis. Sleep Med. 2009 Jan;10(1):47-54
16. Tang SC, Lam B, Lai AS, Pang CB, Tso WK, Khong PL, Ip MS, Lai KN. Improvement in sleep apnea during nocturnal peritoneal dialysis is associated with reduced airway congestion and better uremic clearance. Clin J Am Soc Nephrol. 2009 Feb;4(2):410-8
17. La Manna G, Pizza F, Persici E, Baraldi O, Comai G, Cappuccilli ML, Centofanti F, Carretta E, Plazzi G, Coli L, Montagna P, Stefoni S. Restless legs syndrome enhances cardiovascular risk and mortality in patients with end-stage kidney disease undergoing long-term haemodialysis treatment. Nephrol Dial Transplant. 2011 Jun;26(6):1976-83