Commentary on the NICE guideline on renal replacement therapy and conservative management.

BACKGROUND: NICE Guideline NG107, "Renal replacement therapy and conservative management" (Renal replacement therapy and conservative management (NG107); 2018:1-33) was published in October 2018 and replaced the existing NICE guideline CG125, "Chronic Kidney Disease (Stage 5): peritoneal dialysis" (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, "Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure"(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including "Haemodialysis" (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, "Peritoneal Dialysis in Adults and Children" (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and "Planning, Initiation & withdrawal of Renal Replacement Therapy" (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline). There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.

Home haemodialysis: Providing opportunities to reimagine haemodialysis care.

There has been a resurgence in home haemodialysis over the last decade and interest in its implementation in gaining momentum with advances in technology and healthcare policy initiatives. Both increasing haemodialysis frequency and treatment time have several potential benefits in improving dialysis efficiency and are ideally placed in the home setting. The paper describes the rationale, current status, controversies, challenges and future avenues for home haemodialysis.

Effects of Expanded Hemodialysis Therapy on Clinical Outcomes.

The invention of dialysis has been a phenomenal advance in the treatment of kidney failure. The introduction of artificial kidneys in clinical care remains one of the most successful lifesaving interventions in modern medicine. Its glory, however, has been tempered by poor long-term outcomes and a negative qualitative impact on the lives of patients who suffer from an extremely complex, burdensome, and restricted life on dialysis. There remains a huge gap in patient well-being and outcomes between artificial kidney treatments and kidney transplantation. The inadequacy of dialysis, at least in part, is due to the chronic accumulation of organic retention solutes of middle and large molecules in chronic kidney disease, which are poorly removed by current dialytic treatment modalities. Incremental benefits observed through alternative strategies such as high volume hemodiafiltration, high frequency, and expanded hemodialysis (HD) schedules have had limited success, due to a host of organizational, complex technology need and human factor barriers. Expanded HD (HDx) therapy offers a novel blood purification technology, with the use of high retention onset (HRO) membranes designed to achieve a superior spectrum of solute waste removal in uremia. Limited studies have demonstrated the potential benefit of HRO membranes in reducing cardiovascular risk, vascular calcification, and inflammation commonly associated with the "residual uremic syndrome" and patient symptom burden. Robust and efficient clinical trials are now required to establish the rationale and impact of HDx therapy in driving improvements in both physician- and patient-directed clinical goals and outcomes in dialysis.