Treatment options to intensify hemodialysis

At present, three methods are practiced to intensify hemodialysis (HD): 3 times weekly, 8-hour HD, short daily HD and slow daily nocturnal HD. Three times weekly 8-hour dialysis increase both the dialysis dose and time. The longest experiences are in Tassin. Five-year survival in Tassin was better in all age groups compared with the major registries - Japan, EDTA and US Medicare and more obvious for older age groups. The data of Tassin show that increasing the dialysis time provides better blood pressure control, need for no or less antihypertensive drugs, less intradialytic complications, better middle molecule and phosphate clearance, better nutritional status, less requirement for erythropoietin and increased survival. These data of Tassin could be mainly confirmed in our dialysis center. The main difference to Tassin was that in our center most of the patients still need few antihypertensive drugs. The reasons for the difference are that in Tassin the patients are on very low sodium diet (<5 g/day) and in Tassin extracellular volume (ECV) is reduced as far as possible independent of residual renal function. The concept of our center was to preserve residual renal function and accept slightly higher ECV and few antihypertensive drugs. Another concept to intensify HD is short daily HD (6 times/week for 90-180 min). This form of dialysis is offered as in-center and home HD with and without dialysis partner. All studies demonstrated significant improvement of nutritional status, quality of life, control of blood pressure, phosphate and anemia. Survival of AV fistula even with daily double punctures was excellent. The most extensive form of dialysis is slow daily nocturnal dialysis (6 times/week for 8-10 h). This form of dialysis provides excellent urea, phosphate clearance and fourfold increase of beta(2)-microglobulin clearance. Patients discontinue phosphate binders and several patients need phosphate addition to dialysis. Blood pressure control is excellent, all patients are off antihypertensive drugs. Improvement of nutrition, anemia, blood pressure and quality of life is even more pronounced compared to short daily HD or 3 times weekly 8-hour HD. Nocturnal dialysis was able to improve sleep apnea. Nocturnal dialysis is offered only as home HD with and without dialysis partner. Any patient who could be trained for home HD was eligible. Presence of co-morbidities was not a contraindication.