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

In-center nocturnal hemodialysis (INHD) is a unique form of dialysis treatment that is performed in a dialysis center at night, typically for six or more hours three times per week. INHD offers dialysis patients potential clinical and lifestyle benefits (described in this DMI post). However, INHD may not be appropriate for all patients. The therapy is selected by the physician in discussions with the patient. Thus, it is important to know the characteristics of patients for whom INHD may be particularly beneficial.

Primary characteristics for INHD consideration

Concern with fluid removal rate: INHD can benefit patients who present challenges to safe fluid removal, such as those who require ultrafiltration (UF) at excessive rates (> 10 mL/kg/hr) or those inclined to develop hypotension with volume removal. High ultrafiltration rates (UFRs) may predispose patients to myocardial stunning and ischemic injury from hypoperfusion, which is related to intradialytic hypotension in the setting of uremic reduced capillary density alterations, abnormal vascular autoregulation and preexisting myocardial disease. Additionally, organ stunning can potentially lead to loss in residual renal function, gastrointestinal dysfunction and cognitive function deterioration.

Intolerance to standard in-center hemodialysis (ICHD): Patients with uncontrolled hypertension or who are on more than three hypertensive medications despite regular hemodialysis may be good INHD candidates. In addition, the potential benefits of the modality may be particularly appealing to patients who complain of long post‑dialysis recovery times or issues with sexual dysfunction, and those experiencing a decrease in energy levels.

The desire to maintain employment and avoid work-schedule disruption: Preserving employment status is a strong consideration for patients considering INHD over standard ICHD, the latter of which may be more likely to interfere with a patient’s work status. Studies have linked continued employment with improved outcomes.

Additional characteristics

Patients transitioning from chronic kidney disease (CKD) to end stage renal disease (ESRD): Several characteristics and life-status milestones may make patients transitioning to dialysis good candidates for INHD, including:

• Scheduled transplant from living related donors (LRDs) not interested in home modalities
• Employed and not wanting to dialyze at home
• Daytime transportation issues
• High morbidity or comorbidity with hypoalbuminemia, edema, history of congestive heart failure (CHF) and hypotension
• Desire to preserve residual renal function on an in-center modality
• Young age and wanting to preserve health
• Transplant candidates with left ventricular hypertrophy (LVH) at baseline, not wanting home hemodialysis
• Cardiomyopathy ejection fraction < 30% and/or hypotension
• Absence of end-organ damage and a desire to preserve organ function and maintain health
• Carpal tunnel and an increase in beta-2-microglobulin

The above characteristics may be supported by the following objective documentation (although these are not required to prescribe INHD):

• Echo: LVH, increased left ventricular mass index (LVMI), increased left ventricular end diastolic volume (LVEDV), increased left atrium (LA), abnormal right ventricle (RV),pulmonary hypertension or reduced ejection fraction(< 30 %)
• Tilt table testing abnormalities, hemodynamic instability
• ICHD rounding report (observed change in clinical status): recent coronary artery disease (CAD), hypotension, autonomic insufficiency, excessive UF requirements (>13 mL/kg/hr), recent cardiovascular hospital admission, change in hemodynamic tolerance of ICHD
• Lab test: elevated beta-2-microglobulin (> 35 mg/L), loss in risk factor control on standard ICHD, PD or HHD
• Clinical history: hypotension (< 90/70 mmHg), malnutrition (albumin < 3.0 g/L), abnormal subjective global assessment (SGA), persistent edema, uncontrolled hypertension (> 160/90 mmHg) on multiple medications, not interested in home dialysis
• Transplant options: non-transplant candidates, longer waiting time by low organ availability or highly sensitized patient status (high PRA)

Prevalent ESRD patients considering a modality transfer: INHD may benefit dialysis patients who want to address comorbidity risk factors and are unresponsive or fail to improve while on another treatment modality. Potential candidates include—among others—

• Transplant candidates
• On ICHD with
  • CAD and uncontrolled hypertension
  • LVH and uncontrolled hypertension
  • High UF treatment requirements
  • Daytime transportation issues
  • Long recovery and hypotension due to poor ICHD tolerance
• Peritoneal dialysis (PD) failure and disinterest in home hemodialysis (HHD)
• Employment demand requiring change in dialysis times

Please note the list above is not exhaustive but includes some of the most likely candidates. The above characteristics may be supported by the following objective documentation (although these are not required to prescribe INHD):

• ICHD rounding report: UFR > 13 mL/kg/hr, UF intolerance, unstable blood pressure
• Clinical history: long recovery period for ICHD
• Quality metrics data: increased phosphorus (> 6.0 mg/dL) despite medications, increased B2 microglobulin
• Rounding data and 24-hour ambulatory monitor: uncontrolled hypertension (> 160/90 mmHg) on anti-hypertensive medications, nocturnal non-dipper
• Hospital discharge summary: ICHD patients with multiple cardiovascular related admissions within three months,
• PD clinical records: documented PD inadequacy and/or UF failure (< 400 mL @ 4 hr with 4.25%) plus edema or hypervolemia, worsening clinical or QOL status
• Acuity testing: recent change in Charlson acuity score (Charlson Comorbidity Index > 4) with an opportunity for improvement with INHD

Patients who may be unfit for INHD

In selecting patients for INHD, physicians should consider alternative treatment options for patients with a high acuity score, who require a level of nursing care that puts too great a burden on a nocturnal staff. Patients who are unable to ambulate into the unit (stretcher patients), who require frequent vital sign checks or are clinically unstable post hospitalization, or warrant other special attention may not be a good fit for INHD programs. In addition, nocturnal programs may not be suitable for patients who have behavior problems or are potentially disruptive. Such patients often require excessive attention from dialysis staff and can make the dialysis experience unacceptable to other patients who are trying to sleep. The basic tenet is to consider alternative treatment options for any patients who may pose safety risks on INHD shifts due to level of acuity and care needs.

Summary

The longer, slower dialysis treatments of INHD may be particularly beneficial to certain types of patients, whose characteristics have been outlined above. In addition to these optimal patient characteristics, physicians should be aware of other patient types who may be better candidates for treatment options other than INHD.

Upcoming post: In-Center Nocturnal Hemodialysis, Part III: Prescription and Operational Guidelines