Frequent dialysis: it’s complicated

Patients who undergo hemodialysis on a frequent basis are at an increased risk for vascular access complications, requiring more vascular repair procedures to enable continued access to the blood, report Canadian researchers.

"Our study is the first randomized trial to show that dialyzing more frequently may have potential harmful effects on the hemodialysis vascular access," said lead author Rita Suri from the University of Western Ontario in London, in a press statement. "This has important implications for patients and physicians considering or performing frequent hemodialysis."

In the Frequent Hemodialysis Network (FHN) Daily Trial the team compared vascular access outcomes for 120 patients randomly allocated to receive conventional hemodialysis (three times per week) with those of 125 patients who received frequent hemodialysis (six times per week). In addition, the researchers conducted the FHN Nocturnal Trial, in which 42 patients receiving conventional therapy were compared with 45 patients receiving frequent nocturnal dialysis (6 nights per week) at home.

"The FHN trials are the largest randomized controlled trials to examine whether frequent hemodialysis performed six times per week poses any risks or benefits to the vascular access," write the researchers in the Journal of the American Society of Nephrology.

In the daily trial, 29 (24%) patients from the conventional group versus 48 (38%) from the frequent group had an access-related event. In the conventional group, there were 17 repairs, 11 losses (abandonment of vascular access site), and one access-related hospitalization. This compared with almost double the amount of repairs (n=33) and 15 losses in the daily group.

Compared with patients receiving conventional hemodialysis, the risk for having an access event was a significant 1.8-fold higher among patients who had daily hemodialysis. This risk increased further for patients with an arteriovenous fistula or graft, who were at a 1.9-fold greater risk, and further still for patients with catheters, who were at a 2.7-fold greater risk.

Similar trends were observed in the nocturnal trial, although the results did not reach significance.

"The increased risk of access complications with frequent hemodialysis may have significant clinical impact," write Suri and team. "If repair procedures are not readily available, patients may lose their permanent arteriovenous access and end up with a tunnelled catheter." In addition, both the patients and the care team could become frustrated with the need for frequent repairs and abandon the arteriovenous access in favor of a tunnelled catheter, they note.

"Further studies may help to elucidate the effects of frequent hemodialysis on tunnelled catheter performance and complications, as well as the relative safety of buttonhole versus other cannulation techniques," concludes the team.

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