KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update.

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

In-center hemodialysis education: Challenges and innovations in training of fellows in nephrology.

The in-center dialysis unit and practice of dialysis, in the current multi-team approach, requires knowledge and skills in all the domains including medical expert, communicator, collaborator, scholar, health advocate, and leader. We are tasked as a community, to embrace and incentivize new innovations and technology to address these needs for our post graduate trainees. These innovations must address the basic principles of dialysis, quality improvement, technical and procedural skills as well as leadership and administration skills. The teaching methods and innovations must also be challenged to demonstrate the translation into adoption and improvements in practice to demonstrate success. This article will review the current state of the training curriculum in Nephrology for in-center hemodialysis and address some of the recent innovations.

Complications of the Arteriovenous Fistula: A Systematic Review.

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

The Effect of Predialysis Fistula Attempt on Risk of All-Cause and Access-Related Death.

Whether the lower risk of mortality associated with arteriovenous fistula use in hemodialysis patients is due to the avoidance of catheters or if healthier patients are simply more likely to have fistulas placed is unknown. To provide clarification, we determined the proportion of access-related deaths in a retrospective cohort study of patients aged ≥18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. A total of 3168 patients initiated dialysis at the participating centers; 2300 met our inclusion criteria. Two investigators independently adjudicated cause of death using explicit criteria and determined whether a death was access-related. We observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged <65 years (hazard ratio [HR], 0.49; 95% confidence interval [95% CI], 0.29 to 0.82) and in the first 2 years of follow-up in those aged ≥65 years (HR0-24 months, 0.60; 95% CI, 0.43 to 0.84; HR24+ months, 1.83; 95% CI, 1.25 to 2.67). Sudden deaths that occurred out of hospital accounted for most of the deaths, followed by deaths due to cardiovascular disease and infectious complications. We found only 2.3% of deaths to be access-related. In conclusion, predialysis fistula attempt may associate with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias.

Vascular Access Type and Patient and Technique Survival in Home Hemodialysis Patients: The Canadian Organ Replacement Register.

BACKGROUND: While central venous catheter (CVC) use has expanded home hemodialysis (HHD) eligibility to many patients who may be unable to self-cannulate an arteriovenous (AV) access, the association between CVC use and mortality has not been directly examined among HHD patients. STUDY DESIGN: Registry-based retrospective observational cohort study. SETTING & PARTICIPANTS: Incident HHD patients in The Canadian Organ Replacement Register who had information for vascular access type (CVC vs AV access) within the first year of HHD therapy initiation. PREDICTOR: Use of a CVC versus an AV access (AV fistula or graft) within the first year of HHD therapy initiation. OUTCOME: The composite of all-cause mortality and technique failure (long-term transfer to an alternate dialysis modality). A Cox proportional hazards model was used to evaluate the adjusted composite outcome and each outcome separately. RESULTS: 1,869 patients initiated HHD therapy in Canada in 1996 to 2012, of whom 1,217 had an access type recorded within the first year of HHD therapy initiation. Compared to CVC use (n=523) and during a median follow-up of 513 and 427 days for AV access and CVC patients, respectively, AV access use (n=694) was associated with lower risk for the composite event of death and technique failure (490 events; adjusted HR, 0.78; 95% CI, 0.64-0.94) and lower adjusted all-cause mortality (129 deaths; adjusted HR, 0.63; 95% CI, 0.43-0.91); the risk for technique failure was nominally lower, but this result was not statistically significant (361 events; adjusted HR, 0.84; 95% CI, 0.67-1.05). Results were robust to sensitivity analyses and after missing data imputation. LIMITATIONS: Missing information for vascular access type (n=659[35% of patients]) and lack of information for longitudinal changes in vascular access type. CONCLUSIONS: Compared to CVC use, AV access use was associated with superior survival. Minimizing CVC use and maximizing AV access use while addressing barriers to their placement and self-cannulation may improve HHD outcomes.

International Society of Nephrology-Hydration and Kidney Health Initiative - Expanding Research and Knowledge.

The purpose of this manuscript is to describe a collaborative research initiative to explore the role of hydration in kidney health. Our understanding of the effects of hydration in health and disease is surprisingly limited, particularly when we consider the vital role of hydration in basic human physiology. Recent initiatives and research outcomes have challenged the global medical community to expand our knowledge about hydration, including the differences between water, sugared beverages and other consumables. Identification of the potential mechanisms contributing to the benefits of hydration has stimulated the global nephrology community to advance research regarding hydration for kidney health. Hydration and kidney health has been a focus of research for several research centers with a rapidly expanding world literature and knowledge. The International Society of Nephrology has collaborated with Danone Nutricia Research to promote development of kidney research initiatives, which focus on the role of hydration in kidney health and the global translation of this new information. This initiative supports the use of existing data in different regions and countries to expand dialogue among experts in the field of hydration and health, and to increase scientific interaction and productivity with the ultimate goal of improving kidney health.

Geographic and facility variation in initial use of non-tunneled catheters for incident maintenance hemodialysis patients.

BACKGROUND: Non-tunneled (temporary) hemodialysis catheters (NTHCs) are the least-optimal initial vascular access for incident maintenance hemodialysis patients yet little is known about factors associated with NTHC use in this context. We sought to determine factors associated with NTHC use and examine regional and facility-level variation in NTHC use for incident maintenance hemodialysis patients. METHODS: We analyzed registry data collected between January 2001 and December 2010 from 61 dialysis facilities within 12 geographic regions in Canada. Multi-level models and intra-class correlation coefficients were used to evaluate variation in NTHC use as initial hemodialysis access across facilities and geographic regions. Facility and patient characteristics associated with the lowest and highest quartiles of NTHC use were compared. RESULTS: During the study period, 21,052 patients initiated maintenance hemodialysis using a central venous catheter (CVC). This included 10,183 patients (48.3 %) in whom the initial CVC was a NTHC, as opposed to a tunneled CVC. Crude variation in NTHC use across facilities ranged from 3.7 to 99.4 % and across geographic regions from 32.4 to 85.1 %. In an adjusted multi-level logistic regression model, the proportion of total variation in NTHC use explained by facility-level and regional variation was 40.0 % and 34.1 %, respectively. Similar results were observed for the subgroup of patients who received greater than 12 months of pre-dialysis nephrology care. Patient-level factors associated with increased NTHC use were male gender, history of angina, pulmonary edema, COPD, hypertension, increasing distance from dialysis facility, higher serum phosphate, lower serum albumin and later calendar year. CONCLUSIONS: There is wide variation in NTHC use as initial vascular access for incident maintenance hemodialysis patients across facilities and geographic regions in Canada. Identifying modifiable factors that explain this variation could facilitate a reduction of NTHC use in favor of more optimal initial vascular access.

Hemodialysis Arteriovenous Vascular Access Creation After Kidney Transplant Failure.

BACKGROUND: Little is known about vascular access in patients starting hemodialysis therapy after kidney transplant failure. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adult patients (aged ≥18 years) who started hemodialysis therapy in Ontario, Canada, from January 1, 2001, through December 31, 2010, after kidney transplant failure. PREDICTOR: Patient clinical and demographic characteristics. OUTCOMES: Proportion and timing of arteriovenous (AV) vascular access creation (fistula or graft) 12 months prior and up to 24 months after starting hemodialysis therapy. MEASUREMENTS: Event rates and outcome predictors. RESULTS: Our cohort included 683 patients with a mean age of 48 years and >50% with comorbidity index score < 3. In the 12 months predialysis and 24 months postdialysis, 16% and 47% of patients had an AV access created, respectively. In the postdialysis period, 13%, 26%, and 38% of patients had an AV access creation at 3, 6, and 12 months, respectively. History of coronary artery disease, diabetes mellitus, and peritoneal dialysis use prior to transplantation were associated with a lower likelihood of AV access creation. LIMITATIONS: Residual selection bias from unmeasured variables beyond the data elements. CONCLUSIONS: In Ontario, AV access creation, both before and after starting hemodialysis therapy, is low in patients with kidney transplant failure despite their being younger and healthier compared to the overall hemodialysis population. This highlights the need for a predialysis care pathway in the transplantation clinic and an active strategy to identify this patient cohort receiving hemodialysis to align modality and access choices.

Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator.

BACKGROUND: The effectiveness of various solutions instilled into the central venous catheter lumens after each hemodialysis session (catheter locking solutions) to decrease the risk of catheter malfunction and bacteremia in patients undergoing hemodialysis is unknown. METHODS: We randomly assigned 225 patients undergoing long-term hemodialysis in whom a central venous catheter had been newly inserted to a catheter-locking regimen of heparin (5000 U per milliliter) three times per week or recombinant tissue plasminogen activator (rt-PA) (1 mg in each lumen) substituted for heparin at the midweek session (with heparin used in the other two sessions). The primary outcome was catheter malfunction, and the secondary outcome was catheter-related bacteremia. The treatment period was 6 months; treatment assignments were concealed from the patients, investigators, and trial personnel. RESULTS: A catheter malfunction occurred in 40 of the 115 patients assigned to heparin only (34.8%) and 22 of the 110 patients assigned to rt-PA (20.0%)--an increase in the risk of catheter malfunction by a factor of almost 2 among patients treated with heparin only as compared with those treated with rt-PA once weekly (hazard ratio, 1.91; 95% confidence interval [CI], 1.13 to 3.22; P = 0.02). Catheter-related bacteremia occurred in 15 patients (13.0%) assigned to heparin only, as compared with 5 (4.5%) assigned to rt-PA (corresponding to 1.37 and 0.40 episodes per 1000 patient-days in the heparin and rt-PA groups, respectively; P = 0.02). The risk of bacteremia from any cause was higher in the heparin group than in the rt-PA group by a factor of 3 (hazard ratio, 3.30; 95% CI, 1.18 to 9.22; P = 0.02). The risk of adverse events, including bleeding, was similar in the two groups. CONCLUSIONS: The use of rt-PA instead of heparin once weekly, as compared with the use of heparin three times a week, as a locking solution for central venous catheters significantly reduced the incidence of catheter malfunction and bacteremia. (Current Controlled Trials number, ISRCTN35253449.).

Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry.

BACKGROUND: Several observational studies of hemodialysis patients show an association between early dialysis therapy initiation and increased mortality. Few studies have examined this association among peritoneal dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: A cohort of 8,047 incident peritoneal dialysis patients who started dialysis therapy in 2001-2009 and were treated in Canada. PREDICTOR: Estimated glomerular filtration rate (eGFR) at dialysis therapy initiation. Defined early, mid, and late starts as eGFR>10.5, 7.5-10.5, and <7.5mL/min/1.73m(2), respectively. OUTCOMES: Time to death. MEASUREMENTS: Proportional piecewise exponential survival models to compare mortality (overall and early) for the 3 predictor groups. RESULTS: Between 2001 and 2009, the proportion of patients starting peritoneal dialysis therapy as early starts increased from 29% (95% CI, 26%-32%) to 44% (95% CI, 41%-47%). Compared with the late-start group, the overall mortality rate was not higher for the early- (adjusted HR, 1.08; 95% CI, 0.96-1.23) or mid-start (adjusted HR, 0.96; 95% CI, 0.86-1.09) groups. However, when examined yearly, patients in the early-start group were significantly more likely to die within the first year of dialysis therapy compared with those in the late-start group (adjusted HR, 1.38; 95% CI, 1.10-1.73), but not in subsequent years. LIMITATIONS: Bias and residual confounding may have influenced the observed relationship between predictor and outcome. CONCLUSIONS: Patients are initiating peritoneal dialysis therapy at increasingly higher eGFRs. Contrary to most observational studies assessing hemodialysis, the early initiation of peritoneal dialysis therapy, at eGFR>10.5mL/min/1.73m(2), is not associated with increased mortality.

Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis.

BACKGROUND: Advantages of the arteriovenous fistula (AVF), including long patency and few complications, were ascertained more than 2 decades ago and may not apply to the contemporary dialysis population. STUDY DESIGN: Systematic review and meta-analysis. Estimates were pooled using a random-effects model and sources of heterogeneity were explored using metaregression. SETTING & POPULATION: Patients treated with long-term hemodialysis using an AVF. SELECTION CRITERIA FOR STUDIES: English-language studies indexed in MEDLINE between 2000 and 2012 using prospectively collected data on 100 or more AVFs. PREDICTOR: Age, AVF location, and study location. OUTCOMES: Outcomes of interest were primary AVF failure and primary and secondary patency at 1 and 2 years. RESULTS: 7,011 citations were screened and 46 articles met eligibility criteria (62 unique cohorts; n = 12,383). The rate of primary failure was 23% (95% CI, 18%-28%; 37 cohorts; 7,393 AVFs). When primary failures were included, the primary patency rate was 60% (95% CI, 56%-64%; 13 studies; 21 cohorts; 4,111 AVFs) at 1 year and 51% (95% CI, 44%-58%; 7 studies; 12 cohorts; 2,694 AVFs) at 2 years. The secondary patency rate was 71% (95% CI, 64%-78%; 10 studies; 11 cohorts; 3,558 AVFs) at 1 year and 64% (95% CI, 56%-73%; 6 studies; 11 cohorts; 1,939 AVFs) at 2 years. In metaregression, there was a significant decrease in primary patency rate in studies that started recruitment in more recent years. LIMITATIONS: Low quality of studies, variable clinical settings, and variable definitions of primary AVF failure. CONCLUSIONS: In recent years, AVFs had a high rate of primary failure and low to moderate primary and secondary patency rates. Consideration of these outcomes is required when choosing a patient's preferred access type.

Fistula eligibility: a work in progress.

Effective hemodialysis requires a reliable vascular access. Clinical practice guidelines strongly recommend the fistula as the preferred option followed by arteriovenous (AV) grafts, with central venous catheters being least preferred. Recently, there has been a growing awareness of the limitations of the fistula, its high rate of primary failure and that a fistula may not be appropriate for all patients initiating or on hemodialysis. However, determinates for fistula eligibility have not been clearly defined. The creation and use of a fistula requires the complex integration of patient, biological, and surgical factors, none of which can be easily predicted or planned. There have been several successful initiatives over the last decade addressing patient suitability for AV access, but none have validated defined criteria for fistula eligibility. We discuss these initiatives by addressing: 1) process of care, 2) radiological and nonradiological tests and procedures, and 3) alternative surgical approaches. Careful clinical judgment, appropriate vascular access assessment and placement, and an individualized approach to the risks and benefits will optimize patient health outcomes while minimizing prolonged catheter dependence among hemodialysis patients.

Protection against Incidences of Serious Cardiovascular Events Study with daily fish oil supplementation in dialysis patients (PISCES): protocol for a randomised controlled trial.

INTRODUCTION: Patients with kidney failure with replacement therapy (KFRT) suffer premature cardiovascular (CV) mortality and events with few proven pharmacological interventions. Omega-3 polyunsaturated essential fatty acids (n-3 PUFAs) are associated with a reduced risk of CV events and death in non-dialysis patients and in patients with established CV disease but n-3 PUFAs have not been evaluated in the high risk KFRT patient population. METHODS AND ANALYSIS: This multicentre randomised, placebo controlled, parallel pragmatic clinical trial tests the hypothesis that oral supplementation with n-3 PUFA, when added to usual care, leads to a reduction in the rate of serious CV events in haemodialysis patients when compared with usual care plus matching placebo. A target sample size of 1100 KFRT patients will be recruited from 26 dialysis units in Canada and Australia and randomised to n-3 PUFA or matched placebo in a 1:1 ratio with an expected intervention period of at least 3.5 years. The primary outcome to be analysed and compared between intervention groups is the rate of all, not just the first, serious CV events which include sudden and non-sudden cardiac death, fatal and non-fatal myocardial infarction, stroke, and peripheral vascular disease events. ETHICS AND DISSEMINATION: This study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. TRIAL REGISTRATION NUMBER: ISRCTN00691795.

A multinational cohort study of in-center daily hemodialysis and patient survival.

Increasing hemodialysis frequency from three to six times per week improves left-ventricular mass and health-related quality of life; however, effects on survival remain uncertain. To study this, we identified 556 patients in the International Quotidian Dialysis Registry who received daily hemodialysis (more than five times per week) between 2001 and 2010. Using propensity score-based matching, we matched 318 of these patients to 575 contemporaneous patients receiving conventional (three times weekly) hemodialysis in the Dialysis Outcomes and Practice Patterns Study. All patients had session times of <5 h, and received dialysis in the clinic or hospital setting. Mortality rates between groups were compared using Cox proportional hazards regression. Mean dialysis frequency in the daily group was 5.8 sessions per week. Mean weekly treatment time was 15.7 h for daily and 11.9 h for conventional patients. During 1382 patient-years of follow-up, 170 patients died. Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous studies, we found that in-center daily hemodialysis was not associated with any mortality benefit. Thus, decisions to undertake daily hemodialysis should be based on quality-of-life improvements, rather than on claims of improved survival.

Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD.

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for anemia management in patients with chronic kidney disease provides the structural and evidence base for the Canadian Society of Nephrology commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 11 of the 61 KDIGO guideline statements. Specifically, we agreed that a therapeutic trial of iron is appropriate in cases in which a reduction in erythropoiesis-stimulating agent (ESA) dosage or avoidance of ESA and transfusion is desired, transferrin saturations are >30%, and ferritin concentrations are >500 µg/L. However, we concluded that there is insufficient evidence to support an upper target or threshold for ferritin and transferrin saturation levels. We agree with the initiation of ESA treatment when hemoglobin (Hb) level is 90-100 g/L; however, we specifically state that an acceptable range for Hb level is 95-115 g/L, with a target of 100-110 g/L, and add caution to individualization above this range due to concerns regarding the safety of ESAs. We agree that ESAs should be used with considerable caution in patients with active malignancy, history of stroke, or history of malignancy, and we suggest initiating ESA therapy at Hb level of 90 g/L and to aim for a Hb level in the range of 90-105 g/L. The reader is encouraged to note the level of evidence and review the entire KDIGO anemia guideline to interpret the guideline statements and commentary appropriately.

Education in vascular access.

The successful creation and use of an arteriovenous vascular access (VA) requires a coordinated, educated multidisciplinary team to ensure an optimal VA for each patient. Patient education programs on VA are associated with increased arteriovenous VA use at dialysis initiation. Education should be tailored to patient goals and preferences with the understanding that experiential education from patient to patient is far more influential than that provided by the healthcare professional. VA education for the nephrologist should focus on addressing the systematic and patient-level barriers in achieving a functional VA, with specific components relating to VA creation, maturation, and cannulation that consider patient goals and preferences. A deficit in nursing skills in the area of assessment and cannulation can have devastating consequences for hemodialysis patients. Delivery of an integrated education program increases nurses' knowledge of VA and development of simulation programs or constructs to assist in cannulation of the VA will greatly facilitate the much needed skill transfer. Adequate VA surgical training and experience are critical to the creation and outcomes of VA. Simulations can benefit nephrologists, dialysis nurses surgeons, and interventionalists though aiding in surgical creation, understanding of the physiology and anatomy of a dysfunctional VA, and practicing cannulation techniques. All future educational initiatives must emphasize the importance of multidisciplinary care to attain successful VA outcomes.

Understanding surgical preference and practice in hemodialysis vascular access creation.

Understanding healthcare providers' preferences, values, and beliefs around AVF eligibility is important to explain variability in practice. We conducted a survey of international surgeons, using hypothetical patient scenarios, to assess resources used, variables, perceived barriers, and absolute contraindications to access creation. A total of 134 surgeons completed the survey. Venous duplex ultrasound mapping (VDUM) was offered to all patients by 90% of US, 68% Canadian, and 63% European respondents. VDUM altered clinical decision less than 25% of the time for 33% American, 48% Canadian, and 85% European surgeons. Increased comorbidities and previous failed access were deterrents to AVF creation as was vessel size. Second choice access was the AV graft in the US and Europe and the catheter in Canada. Absolute contraindications to AVF creation included patient life expectancy <1 year, left ventricular ejection fraction (LVEF) <15%, and a history of dementia, while 42% surgeons reported no absolute contraindications. Perceived barriers included patient preferences, long wait times for surgery, and late referral to a Nephrologist. Significant variability exists in the surgical preoperative assessment of patients, and the eligibility criteria used for fistula creation. Understanding surgeons' preferences can aid in establishing standardization for VA access eligibility, including surgical assessment.

Dialysis initiation: what's the rush?

The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m(2) ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off dialysis for years. Delay of dialysis start until a working arterio-venous access is in place seems prudent in light of the lack of harm and possible benefit of late dialysis initiation. Prescribing frequent hemodialysis is not recommended when dialysis is initiated early. The benefits of early initiation of chronic dialysis after episodes of congestive heart failure or acute kidney injury require further study. There are no data to show that early start benefits diabetics or other patient groups. Preemptive start of dialysis in noncompliant patients may be necessary to avoid complications. The decision to initiate dialysis requires informed patient consent and a joint decision by the patient and dialysis provider. Possible talking points for obtaining informed consent are provided.

Intensive hemodialysis associates with improved survival compared with conventional hemodialysis.

Patients undergoing conventional maintenance hemodialysis typically receive three sessions per week, each lasting 2.5-5.5 hours. Recently, the use of more intensive hemodialysis (>5.5 hours, three to seven times per week) has increased, but the effects of these regimens on survival are uncertain. We conducted a retrospective cohort study to examine whether intensive hemodialysis associates with better survival than conventional hemodialysis. We identified 420 patients in the International Quotidian Dialysis Registry who received intensive home hemodialysis in France, the United States, and Canada between January 2000 and August 2010. We matched 338 of these patients to 1388 patients in the Dialysis Outcomes and Practice Patterns Study who received in-center conventional hemodialysis during the same time period by country, ESRD duration, and propensity score. The intensive hemodialysis group received a mean (SD) 4.8 (1.1) sessions per week with a mean treatment time of 7.4 (0.87) hours per session; the conventional group received three sessions per week with a mean treatment time of 3.9 (0.32) hours per session. During 3008 patient-years of follow-up, 45 (13%) of 338 patients receiving intensive hemodialysis died compared with 293 (21%) of 1388 patients receiving conventional hemodialysis (6.1 versus 10.5 deaths per 100 person-years; hazard ratio, 0.55 [95% confidence interval, 0.34-0.87]). The strength and direction of the observed association between intensive hemodialysis and improved survival were consistent across all prespecified subgroups and sensitivity analyses. In conclusion, there is a strong association between intensive home hemodialysis and improved survival, but whether this relationship is causal remains unknown.