By Peter Laird, MD
Nocturnal dialysis became the standard of care early in the course of dialysis as Dr. Stanley Shaldon introduced it to Dr. Scribner in 1964. By the time the ESRD program came into existence in 1973, the majority of patients on dialysis, dialyzed at home, thrice weekly for 8-9 hours each session. Utilizing this schedule, the majority of dialysis patients continued to work and had less than 10% annual mortality. We then entered the era of for-profit dominated in-center dialysis where providers shortened the sessions by increasing the ultrafiltration rates as well as the advent of the high flux artificial kidneys. Since that time, our mortality surpassed those of the other developed nations by a rate of 2.5 times that seen in Japan today. While renal transplant made great strides improving their outcomes, dialysis patients lagged behind in the crowded open ward dialysis clinics. However, one medical group in Tassin France led by Dr. Bernard Charra, a protege of Dr. Scribner, kept the original schedule continuously for the last 40 years with excellent outcomes:
Long slow hemodialysis (3×8 hours/week) has been used in Tassin for 30 years without significant change in the method. It provides excellent results in terms of morbidity and mortality. The better survival than usually reported on shorter dialysis is mainly due to lower cardiovascular mortality. The nutritional state of the patient is good, as well as the correction of anemia with low doses of EPO. But the main feature concerns blood pressure; hypertension is very well controlled without need for antihypertensive medications. The gentle ultrafiltration provided by a long session time associated with a low salt diet and a moderate interdialytic weight gain allows for normalization of the extracellular fluid space in most patients (dry weight) without important intradialytic morbidity. This low salt diet has paradoxically been forgotten in recent years while shortened dialysis time renders it more necessary than ever.
In the early 1990's, the Toronto medical group led by Dr. Uldall and Dr. Pierratos revived the concept of nocturnal dialysis here in North America and took the next step of increasing not only the duration of dialysis, but also the frequency of dialysis from 6-7 sessions per week, creating the first daily nocturnal dialysis program. The initial published reports astounded the renal community with normalized phosphorus levels, reduced dosages of Epogen and prolonged survival in these patients.
There is evidence that high frequency, as well as long duration, hemodialysis provides better clinical outcomes. We developed nocturnal hemodialysis, a new innovative form of renal replacement therapy, which is performed six to seven nights per week for 8 to 10 h during sleep at home. Blood flow was set at 300 ml/min and dialysate flow at 100 ml/min. . . There was hemodynamic stability and significant subjective improvement in patient well being. Nightly Kt/V was 0.99. Weekly removal of phosphate was twice as high and beta2 microglobulin 4 times as high as conventional hemodialysis. All patients have discontinued their phosphate binders and have increased dietary phosphate and protein intake. BP control was achieved with fewer medications. . . Nocturnal hemodialysis represents the most efficient form of dialysis at low cost and should be considered as an option for patients who can be trained for home hemodialysis.
By the end of the decade, Dr. Lockridge in Virginia and Dr. Agar in Australia converted many of their patients to daily, nocturnal dialysis with the same magnitude of beneficial outcomes as seen in the original studies by Dr. Uldall and Pierratos. In 2009, Dr. Pauly and his colleagues gathered 177 nocturnal hemodialysis patients from two Canadian centers showing that this treatment had equal survival to cadaveric transplant patients:
Results. The total study population consisted of 177 NHD patients matched to 1062 DTX and LTX recipients (total 1239 patients) followed for a maximum of 12.4 years. During the follow-up period, the proportion of deaths among NHD, DTX and LTX patients was 14.7%, 14.3% and 8.5%, respectively (P = 0.006). We found no difference in the adjusted survival between NHD and DTX (HR 0.87, 95% CI 0.50–1.51; NHD reference group), while LTX survival was better (HR 0.51, 95% CI 0.28–0.91).
Conclusions. These results indicate that NHD and DTX survival is comparable, and suggest that this intensive dialysis modality may be a bridge to transplantation or even a suitable alternative in the absence of LTX in the current era of growing transplant waiting lists and organ shortage.
We have now returned full circle to the basic tenants of the pioneers of hemodialysis who gave increasing dosages at more frequent sessions each week until they rehabilitated their patients. When a patient regressed, they increased the time on dialysis until the patient improved again. Dr. Uldall and Pierratos took up where the pioneers had left off with long, gentle nocturnal treatments and completed what the early researchers were unable to complete due to lack of funds and available machines, they evaluated hemodialysis maximum duration and maximum frequency coupled together for the first time. The fact that survival with daily nocturnal dialysis is now equivalent to cadaveric transplant survival opened the doors to optimal dialysis strategies throughout the world.
In truth, this is Dr. Scribner's vision completed, yet far too many patients in need of home hemodialysis and its proven benefits cannot overcome the many barriers to access this modality, not the least of which is the ponderously slow acceptance by the American nephrology community as well as many insurance companies. The expected lifespan of over 70% survival after 10 years of nocturnal home hemodialysis demands an answer to those unable to remove the barriers to care. It is time to bring this lifesaving procedure the real full circle by now making it available to all capable patients who request it.