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In-Center Nocturnal Hemodialysis, Part I: Clinical Benefits

In-center nocturnal hemodialysis (INHD) is a hybrid in-center modality administered at a dialysis facility at night for six to eight hours, typically beginning between 5 p.m. and 9 p.m., three times per week. The longer, gentler treatment times that distinguish INHD are critical to the modality’s potential clinical and lifestyle benefits. A nocturnal program, can help dialysis centers attract and retain working patients, increase capacity, and improve overall clinical outcomes and patients’ quality of life (QOL).

Most reports on INHD are observational in nature; nevertheless, there are several consistent findings that highlight its potential clinical benefits. Lacson et al summarized a cohort study on 746 INHD patients matched to 2,062 in-center hemodialysis (ICHD) patients by propensity score, geographic area, and incident patient status. One-year mortality rates were 9 percent for INHD and 15 percent for ICHD, and two-year mortality rates were 19 percent and 27 percent, respectively. This represents a 27 percent relative risk reduction by the first year and a 25 percent relative risk reduction by the second year with INHD. The mean dialysis adequacy (Kt/V) for patients who converted from ICHD to INHD increased from 1.4 to 2.3, while the mean ultrafiltration rate (UFR) decreased 45 percent—from 11 mL/kg/hr to 6 mL/kg/hr. Lowering UF rates to this level theoretically avoids kidney stunning and preserves intravascular perfusion volume . Among laboratory parameters, phosphorus decreased from 5.73 mg/dL to 5.02 mg/dL (P < 0.001).

In addition, a prospective trial matched 247 INHD patients and 247 period-prevalent ICHD patients based on age, gender and the presence of diabetes, and noted a 72 percent relative mortality risk reduction in the INHD cohort over an average follow-up of 11.3 months.

Jakubovic et al reviewed world-wide experiences with INHD and the associated literature (22 total studies), focusing on hospitalization rates, cardiovascular remodeling, volume and blood pressure (BP) control, phosphate and mineral metabolism, anemia, sleep abnormalities and overall QOL. The studies indicated that INHD is associated with fewer hospital days per 100 patient months, regressed left ventricular hypertrophy (LVH) and left atrial diameter, and improved ejection fraction—although this observation warrants further study. Patients demonstrated improved BP control, a reduced need for anti-hypertensive medications, and maintained hemoglobin levels with a mild decrease in erythropoiesis stimulating agent (ESA) dosage patterns. INHD patients also demonstrated improved daytime function, oxygen desaturation index levels and sleep quality. They reported better QOL, heartier appetites, higher energy levels, fewer intra-dialytic cramps and shorter post-treatment recoveries. The main challenges for patients on INHD included sleeping difficulties in the dialysis center, with frequent interruptions by treatment safety monitoring protocols, such as checking BP.

Even with its challenges, INHD is a unique form of dialysis treatment that offers a variety of potential clinical and lifestyle benefits. The reduction in UF achieved with extended time on treatment may play a key role in helping to avoid kidney, brain, and cardiac stunning, which are key clinical risks when on standard ICHD. INHD constitutes a significant opportunity both to improve clinical outcomes for patients and to increase capacity at existing dialysis facilities.

Upcoming post: In-Center Nocturnal Hemodialysis, Part II: Optimal Patient Characteristics

Martin Schreiber, MD

Martin Schreiber, MD

With nearly 40 years of experience in nephrology, Martin Schreiber, MD, serves as chief medical officer for DaVita Kidney Care's home modalities. Before this role, he worked primarily with Cleveland Clinic and held a number of key positions there, including member of the Board of Governors, chairman of the Department of Nephrology and Hypertension and director of home dialysis.