| BackgroundEnd-stage renal disease (ESRD) is the common clinical syndrome of renal failure due to primary or secondary kidney damage. In addition to chronic glomerulonephritis, many diseases such as hypertension, diabetes, gout, systemic lupus erythematosus, etc. could lead to chronic kidney disease. With the increase in the incidence of these diseases, as well as an aging population, environmental pollution and other factors, ESRD incidence gradually increased and has become a major killer of human health. According to the United States Renal Database (USRDS) survey, the incidence of ESRD in1981was92.8cases/million people, gradually increased in recent years, in2002reached to333.2cases/million people and in2006reach to360cases/million people, thus led to the severe global economic burden. As China is entering the aging society, coupled with a large population base, causing a high incidence of kidney damage disease, suffering from ESRD patients has gradually increased. It is expected that the prevalence of ESRD patients will reach1200cases per million people by2020. ESRD has become a common clinical disease, and require renal replacement therapy (RRT). Currently the main methods of renal replacement therapy are kidney transplantation, peritoneal dialysis (PD) and hemodialysis (HD), and the most widely used method at home and abroad is maintenance hemodialysis (MHD).MHD patients may present with a variety of complications, including anemia, mineral and bone disorder (MBD) such as hyperphosphatemia and secondary hyperparathyroidism (SHPT), which are more common and dangerous complications. Its pathogenesis is complex, not only in itself cause harm to patients, and can cause multiple organ damage, such as ischemic tissue and organ damage, ischemic heart disease, fibrocystic osteitis, bone pain and fractures, arthritis and periarthritis, myopathy, spontaneous tendon rupture, skeletal deformities and growth retardation, skin itching, and bone metastatic calcification, hypertension, atherosclerosis, immune dysfunction, etc., can affect the rate of hospitalization and mortality, and seriously affect the quality of life (QOL).Early dialysis hemodialysis dialysis treatment model is once a week. After years of continuous improvement, studies have found that dialysis three times a week (once a day), four hours each treatment can significantly improve the clinical effect. Because of convenience and economic reasons, the model has become the most classic conventional hemodialysis dialysis mode, and continue to promote throughout the world, and it is currently the most widely used of conventional hemodialysis dialysis mode in China. However, because of dialysis once every2-3days, the patient’s fluid volume, biochemical parameters and internal environment fluctuate greatly, so it does not meet the characteristics of human physiology, and this non-physiological dialysis modality may be the main reason leading to complications.In order to improve clinical outcomes and quality of life in dialysis patients, domestic and foreign medical workers constantly improve dialysis prescription by changing the frequency and treatment duration. So many dialysis mode was invented, short daily hemodialysis (SDHD) is one of them. Compared with conventional hemodialysis (CHD), the biggest difference of SDHD is that the frequency is from three times a week to six times a week, and each treatment last from4hours to2hours. Various toxins in CHD patients after dialysis decrease significantly, and they accumulate again in the intervening two days and reach a peak at the next dialysis, meanwhile the environment changed much; In contrast, SDHD has many advantages, such as shorter dialysis interval, lower peak accumulation of toxins, smaller changes in the internal environment, closer to the body’s normal physiological state, etc.In recent years, more in-depth studies from different countries and different periods have confirmed that SDHD can improve clinical outcomes, including anemia, calcium and phosphorus metabolism, SHPT and quality of life in MHD patients. But the study concerning SDHD in mainland China is fewer. Since the background about weight and hemodialysis mode in MHD patients in mainland China are different with foreign patients, whether SDHD could improve clinical outcomes in patients with MHD in mainland China is still unknown. To get clinical data concerning SDHD applied to Chinese, to evaluate whether SDHD could become better treatment modality in MHD patients, to provide the basis for domestic SDHD applications, and to explore more efficient, more physiological, more practical methods of improving clinical outcomes eventually, we designed and conducted this study.ObjectiveThe MHD hemodialysis patients were converted from CHD to SDHD in the present study. The study used self-control and parallel standard control to investigate:(1) whether SDHD could impact on renal anemia and Recombinant human erythropoietin (rHuEPO) requirements in MHD patients.(2) whether SDHD could affect serum phosphorus, calcium-phosphorus product and SHPT in ESRD hemodialysis patients.(3) whether SDHD could improve the quality of life in ESRD hemodialysis patients.(4) whether SDHD could improve anemia, SHPT and the quality of life (QOL) and verify whether the improvement in anemia and SHPT play a role in the improvement in QOL.(5) whether SDHD could affect both SHPT and renal anemia, and verify whether SHPT play a role in the pathogenesis of anemia.(6) whether dialysis adequacy changes compared with CHD.(7) whether SDHD could become better treatment modality in ESRD hemodialysis patients, and to provide a basis in the domestic application of SDHD.Material and MethodsThe subjects were27patients (SDHD group) and30patients (CHD group) with ESRD undergoing hemodialysis in An Hui Provincial Hospital Hemodialysis Unit. All of them have been undergoing CHD using a native arteriovenous fistula or central venous cuffed dual-lumen catheter for8months or longer, able to visit the hospital for SDHD sessions. All patients gave their informed consent. There were no specific patient selection criteria. The subjects in SDHD group or CHD group underwent SDHD or CHD for6months following a baseline observation period for1month (SDHDo or CHDo period). The hematologic parameters and Weekly standard Kt/V (stdKt/V) in SDHD group were measured prior to the conversion from conventional hemodialysis to short daily hemodialysis (SDHDo), at3months after the conversion (SDHD1), and at6months after the conversion (SDHD2). The hematologic parameters and Weekly standard Kt/V (stdKt/V) in CHD group were measured after baseline observation period for1month (CHDo), at3months after CHD0(CHD1), and at6months after CHD0(CHD2). The quality of life (QOL) of patients was evaluated at baseline (SDHDo or CHDo) and6months after the conversion from CHD to SDHD (SDHD2) or6months after CHDo (CHD2) using the Medical Outcomes Study (MOS)36-item Short Form Health Survey (SF-36).Recombinant human erythropoietin (rHuEPO) was administered by subcutaneous injection maximally3times per week to maintain hemoglobin levels within the target range of110to120g/L (11to12g/dL)(K/DOQI guidelines). Iron was administered either orally (150to300mg per day) or intravenously (50to150mg per week) to maintain transferrin saturations greater than20%or serum ferritin levels at greater than200ng/ml. The information on dosage and administration about other drugs (folate, vitamin B12, etc.) used concomitantly throughout the study had been recorded.Dialysate flow rate was500ml/min. Blood flow rate ranged between350and450ml/min. High-flux polysulfone dialyzers and the Fresenius4008S (Fresenius Medical Care, Bad Homberg, Germany) dialysis machines were used in all patients. The hemodialysis conditions, including dialysis prescription and total weekly hemodialysis time, was designed the same in the CHD periods and the SDHD periods.Data are expressed as the mean values±standard deviation. Statistical analysis was performed by using the Student’s paired t-test or Independent sample t-test for measurement data and Wilcoxon test for ordered categorical data, A p value<0.05was considered significant.ResultsAll subjects tolerated SDHD or CHD well and no severe hemodialysis complications occurred in the course of this study.4patients discontinued SDHD therapy in SDHD group before the study course was finished:two patients had difficulty in visiting the hospital6days per week, one patient received a renal transplant and one patients terminated SDHD for having not enough money, one patient discontinued CHD therapy in CHD group because of receiving a renal transplant before the study course was finished.(Table1)1AnemiaThe hematologic parameters on anemia are shown in Table2. The hemoglobin concentration (Hb) in SDHD group increased significantly from107.4±7.9g/L on conventional hemodialysis to114.4±6.8g/L (p<0.05) at SDHD1, and118.3±8.4g/L (p<0.001) at SDHD2, and there was no statistical significant difference between SDHD1and SDHD2(Figure1,2). However, there was no statistical significant difference in Hb in CHD group among CHD0, CHD1and CHD2and between SDHD0and CHD0(Figure3,4). The Hb increased significantly from103.4±7.6g/L at CHD1to114.4±6.8g/L at SDHD1(p<0.001), and from106.9±11.2g/L at CHD2to118.3±8.4g/L(p<0.001) at SDHD2. Meanwhile, there was no statistical significant difference in Hb between SDHD0and CHD1and between SDHD0and CHD2.(Figure5,6)Meanwhile, the rHuEPO dose requirement decreased from6847.8±1057.3u/week at SDHD0to6358.7±1354.3u/week at SDHD1, and5869.6±1094.6u/week (p<0.05) at SDHD2in SDHD group. There was no statistical significant difference between SDHD1and SDHD2(Figure2,7). The rHuEPO dose requirement in CHD group were6681.0±1170.5u/week at CHD0,6422.4±1366.2 u/week at CHD1and6724.1±969.0u/week at CHD2(Figure8). There was no statistical significant difference between SDHDo and CHDo and between SDHD1and CHD1(Figure2,7). However, The rHuEPO dose requirement decreased from6724.1±969.0u/week at CHD2to5869.6±1094.6u/week at SDHD2. Meanwhile, there was no statistical significant difference between SDHDo and CHD1and between SDHD0and CHD2.(Figure9,10)A increase in the serum ferritin (SF) was observed from241.0±35.6ng/ml at SDHDo to244.6±37.9ng/ml at SDHD1, and253.1±32.8ng/ml at SDHD2. However, there was no statistical significant difference in SF among any of the three periods. The SF in CHD group were243.4±39.3ng/ml at CHD0,249.2±28.7ng/ml at CHD1and239.4±40.7ng/ml at CHD2. There was no statistical significant difference among CHD0, CHD1and CHD2, and CHD0vs. SDHD0, CHD1vs. SDHD1, CHD2vs. SDHD2, SDHD0vs. CHD1and SDHD0vs.CHD2.(Figure11)The SF were consistently greater than200ng/ml and the transferrin saturations (TSAT) were consistently greater than20%at all times. There was no statistical significant difference from transferrin saturations, folate or Vitamin B12among any of the three periods (Figure12-14).2Serum phosphate, calcium and parathyroid hormone (PTH)Predialysis serum phosphate concentrations reduced from2.54±0.32mmol/L at SDHD0to2.15±0.36mmol/L (p<0.001) at SDHD1and1.97±0.33mmol/L (p<0.001) at SDHD2. The serum phosphate concentrations in CHD group were2.58±0.33mmol/L at CHD0,2.44±0.35mmol/L at CHD1and2.50±0.39mmol/L at CHD2. There was no statistical significant difference among CHD0, CHD1and CHD0, and between SDHD0and CHD0. However, the serum phosphate concentrations decreased from CHD1to SDHD1(p<0.05) and CHD2to SDHD2(p<0.001). Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.(Figure15,16)The serum calcium concentrations were2.02±0.28mmol/L at SDHDo,1.97±0.24mmol/L at SDHD1,2.04±0.25mmol/L at SDHD2,2.07±0.25mmol/L mmol/L at CHD0,2.01±0.27mmol/L at CHD1and1.95±0.26mmol/L at CHD2. There was no statistical significant difference in serum calcium in SDHD and CHD groups, and CHD0vs. SDHD0, CHD1vs. SDHD1and CHD2vs. SDHD2. Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.(Figure17,18)A significant decrease in Calcium×phosphate (CaxP) product was also observed from5.18±1.24mmol2/L2at SDHD0to4.20±0.71mmol2/L2at SDHD1(p<0.001) and4.02±0.83mmol2/L2at SDHD2(p<0.001). The CaxP product in CHD group were5.32±0.87mmol2/L2at CHD0,4.90±0.90mmol2/L2at CHD1and4.88±1.04mmol2/L2at CHD2. There was no statistical significant difference among CHD0, CHD1and CHD0, and between SDHD0and CHD0. However, the CaxP product decreased from CHD1to SDHD1(p<0.05) and CHD2to SDHD2(p<0.05). Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.(Figure19-22)The PTH levels reduced from223.9±124.7pmol/L at SDHD0to202.0±113.4pmol/L at SDHD1, and196.3±101.3pmol/L(p<0.05) at SDHD2(Figure23). The PTH levels in CHD group were228.9±141.5pmol/L at CHD0,216.9±136.1pmol/L at CHD1and258.5±114.6pmol/L at CHD2. There was no statistical significant difference among CHD0, CHD1and CHD0, and SDHD0vs. CHD0, SDHD1vs. CHD1. The PTH levels decreased from CHD2to SDHD2(p<0.05)(Figure24,25). There was no difference in phosphate binders used before and after conversion to SDHD. Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.(Table3)3Other hematologic and hemodialysis parametersThe Serum albumin concentration (Alb) increased significantly from30.4±3.5g/L at SDHD0to39.2±4.7g/L (p<0.001) at SDHD1, and41.2±4.4g/L (p<0.001) at SDHD2. There was no statistical significant difference in Alb between SDHD1and SDHD2. The Alb in CHD group were29.7±3.6g/L at CHD0,32.4±6.5g/L at CHD1and31.3±4.4g/L at CHD2. There was no statistical significant difference among CHD0, CHD1and CHD0, and SDHD0vs. CHD0. The PTH levels increased from CHD1to SDHD1(p<0.05) and CHD2to SDHD2(p<0.05)(Figure26,27). Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.The CRP decreased from6.2±3.3mg/L at SDHD0to5.6±2.1mg/L at SDHD1, and5.8±2.7mg/L at SDHD2. However, there was no statistical significant difference from CRP among SDHD0, SDHD1and SDHD2. The CRP in CHD group were243.4±39.3ng/ml at CHD0,249.2±28.7ng/ml at CHD1and239.4±40.7ng/ml at CHD2. There was no statistical significant difference among CHDo, CHD1and CHD2, and CHD0vs. SDHD0, CHD1vs. SDHD1and CHD2vs. SDHD2. Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.(Figure28,29)The weekly stdKt/V increased significantly from2.05±0.13at SDHD0to2.73±0.20(p<0.001) at SDHD1, and2.84±0.26(p<0.001) at SDHD2(Figure30). The weekly stdKt/V in CHD group were2.11Q0.25at CHD0,2.08±0.18at CHD1and2.15±0.26at CHD2. There was no statistical significant difference among CHD0, CHD1and CHD0, and SDHD0vs. CHD0. The weekly stdKt/V increased from CHD1to SDHD1(p<0.001) and CHD2to SDHD2(p<0.001)(Figure31,32). Meanwhile, there was no statistical significant difference between SDHD0and CHD1and between SDHD0and CHD2.(Table4)4Quality of lifethe physical and mental health scores were improved after switched to SDHD for6months. The General Health scores increased from26.22±11.84at SDHD0to37.43±15.51at SDHD2(p<0.05) and from28.17±13.53at CHD2to37.43±15.51at SDHD2(p<0.05). There was no statistical significant difference between CHDo and SDHDo and between CHD2and CHDo. Meanwhile, there was no statistical significant difference between SDHDo and CHD2(Figure33). The Physical Functioning scores increased from50.65±13.51at SDHDo to61.96±12.86at SDHD2(p<0.05) and from48.97±14.54at CHD2to61.96±12.86at SDHD2(p<0.05). There was no statistical significant difference between CHDo and SDHDo and between CHD2and CHDo. Meanwhile, there was no statistical significant difference between SDHDo and CHD2(Figure34). The Bodily Pain scores increased from52.57±16.89at SDHDo to63.96±19.81at SDHD2(p<0.05) and from51.72±20.05at CHD2to63.96±19.81at SDHD2(p<0.05). There was no statistical significant difference between CHDo and SDHDo and between CHD2and CHDo. Meanwhile, there was no statistical significant difference between SDHDo and CHD2(Figure35). The Vitality scores increased from31.09±12.79at SDHDo to38.26±14.27at SDHD2(p<0.05) and from30.34±11.72at CHD2to38.26±14.27at SDHD2(p<0.05). There was no statistical significant difference between CHDo and SDHDo and between CHD2and CHD0. Meanwhile, there was no statistical significant difference between SDHDo and CHD2(Figure36). The Mental Health scores increased from52.52±16.81at SDHD0to63.48±18.50at SDHD2(p<0.05). There was no statistical significant difference in CHD0vs. SDHDo, CHD2vs. CHD0and CHD2vs. SDHD2. Meanwhile, there was no statistical significant difference between SDHDo and CHD2(Figure37). The Role-Emotional scores increased from44.82±20.49at CHD2to59.44±28.35at SDHD2(p<0.05). There was no statistical significant difference in CHD0vs. SDHD0, CHD2vs. CHDo, SDHD0vs. SDHD2and SDHDo vs. CHD2(Figure38). However, there was no statistical significant difference in the changes in social functioning, Role-Physical (Figure39,40).Conclusion1Successfully established short daily hemodialysis modality, and apply it to some MHD patients for6months.2Compared with CHD, SDHD may improve anemia and reduce the rHuEPO dose requirement.3SDHD may reduce serum phosphate concentrations.4SDHD may reduce Ca×P product.5The PTH levels decreased after SDHD treatment, so SDHD may be an effective way to improve SHPT in addition to medical and surgical treatment. 6SDHD could improve both anemia and SHPT, which further validates SHPT may be one of the main reason to lead to the development of renal anemia in MHD patients.7SDHD may improve quality of life.8Anemia, SHPT and quality of life were improved after SDHD treatment, which suggests that the improvement in anemia and SHPT play a role in the improvement in QOL.9SDHD may be more adequate than CHD;10SDHD may be more efficient hemodialysis modality in MHD patients in China. |
PDF Full Text Request