Among patients undergoing RRT for ESKD, there are significant differences in quality of life by treatment modality. Users of in-center hemodialysis therapy have the poorest average quality of life, less than users of home dialysis—peritoneal dialysis or home hemodialysis—and considerably less than kidney transplant recipients (1,2). Because the supply of kidneys available for transplant is limited and home dialysis is not always available or appropriate, nearly 90% of United States patients undergo in-center hemodialysis (3). It is incumbent on dialysis care providers and researchers to identify and implement strategies to improve the quality of life of patients on in-center hemodialysis.
Extended hours hemodialysis (≥24 h/wk) supports slower, more gentle fluid removal, and it has the potential to induce fewer significant drops in intradialytic BP. Consequently, it holds the promise of improved clinical outcomes—reduced adverse cardiovascular events, better control of uremic toxins, and improved regulation of potassium, phosphorus, and other electrolytes—versus conventional in-center hemodialysis (about 12 h/wk). Such improvements in health outcomes could naturally translate into improved quality of life. However, extended hours dialysis could also negatively affect patient quality of life because of the extra clinic time—and potentially, extra travel time—that adherence to the treatment protocol demands. These opposing mechanisms may help to explain why to date studies, including both observational studies and randomized clinical trials, have drawn mixed conclusions about the effects of extended hours dialysis on both clinical and quality of life outcomes.
Dialysis providers will keenly follow this developing literature so that they may ensure that the dialysis treatments that they prescribe maximize their patients’ wellbeing. In the United States, extended hours dialysis also has implications for dialysis providers’ reimbursement. The set of quality measures for which providers are held accountable—and potentially, financially penalized—through the ESKD Quality Incentive Program includes a measure of dialysis adequacy (Kt/V) and will soon include a measure of dialysis session ultrafiltration rates (4), both of which can be achieved more readily when treating with extended hours dialysis sessions (4). Thus, providers will, on average, see an increase in per treatment payments from Medicare—the largest payer of dialysis services—when ultrafiltration rates are lower and treatments are longer for at least some patients. Providers may also take interest in treating patients with ESKD with extended hours dialysis outside of the clinic setting. Under the Trump Administration’s Advancing American Kidney Health initiative, in 2020 dialysis providers will be incentivized through the ESKD Treatment Choices payment model to expand access to home hemodialysis treatment, which is often administered in extended hours sessions.
In this issue, Smyth et al. (5) offer new evidence on the question of how patient quality of life is affected by extended hours hemodialysis: the results of a multinational trial of the approach conducted in Australia, Canada, China, and New Zealand. The researchers compared patient-reported quality of life outcomes quantified using multiple measures across 12 months of 200 patients randomized to hemodialysis treatment over extended hours or conventional hemodialysis (including about three quarters in-center hemodialysis and the rest home hemodialysis at first treatment). They observed a small positive relationship between extended hours dialysis and quality of life, although these results did not persist in all reported models. In general, the magnitude of the relationship was relatively small in comparison with what has been observed in other comparisons of quality of life across dialysis modalities (e.g., transplant versus in-center hemodialysis) (1,2).
Among the strengths of this study’s evidence are the use of multiple measures of quality of life and its multinational setting, both of which serve to corroborate key findings. The authors also give thoughtful consideration to the quality of life measurement tools that they use, recognizing that they must be assessed carefully across different cultural contexts. In addition, Smyth et al. (5) take care to interpret their results alongside the results of a detailed meta-analysis of all randomized trials of extended hours dialysis to date.
The study has some important limitations as well. The study sample was not large, including only 200 patients at the beginning of the study period, and therefore, potentially informative subgroup analyses could not be conducted at the study’s conclusion. Patients were followed for only 12 months, although the potential clinical benefits of extended hours hemodialysis could accrue (or manifest) over a longer time window. Additionally, as the authors note, because the analysis does not adjust for multiple comparisons, we are unable to draw any “robust conclusions” from their analysis.
In considering how to weigh this study’s findings and specify future directions in this literature, it is important to ask how dialysis providers might leverage new evidence on the relative outcomes associated with extended hours hemodialysis treatment and how much evidence would be required before a dialysis provider would be justified in taking such action. Suppose, for example, that the evidence comes to show that, on average, extended hours dialysis has advantages—perhaps some marginal reduction in hypotension and elevated quality of life—among certain patients who opt for this protocol. Might some providers—spurred to act by new incentives under the Advancing American Kidney Health initiative—choose to routinely offer their patients the option of extended hours dialysis at home, except for patients who have an absolute contraindication to this treatment approach? At a minimum, the evidence required to justify a new approach such as this would need to include more consistently positive results drawn from trials as well as observational studies and samples large enough to support subgroup analyses that could identify heterogeneous treatment effects. To date, studies investigating whether extended hours hemodialysis protocols are better in general for patients than conventional hemodialysis have not produced evidence approaching any such standards, although subsets of this evidence (e.g., on nocturnal dialysis) offer more consistent conclusions (6,7).
Following on the work of Smyth et al. (5), several aspects of this research question merit further study. More evidence is needed on the relative effects of increased treatment frequency (i.e., a greater number of treatments per week and potentially fewer hours per treatment) versus increased treatment duration (i.e., fixing three treatments per week but increased hours per treatment) on patient health and quality of life outcomes. It is also unclear whether the benefits of extended hours hemodialysis, when observed, may be concentrated in at-home patients versus in-center patients. The timing of treatments (e.g., overnight versus daytime), the different dialysis technologies used (e.g., in terms of ease of use or portability), and whether treatments were provided with staff assist versus alone or with a family member could moderate these relationships as well. Other clinical effects (e.g., BP changes, laboratory values, etc.) of extended hours dialysis are also underexamined. These considerations were not discussed by Smyth et al. (5) and should be points of focus in future studies.
In addition, dialysis providers must reflect on the nonclinical, psychosocial characteristics of patients who may be eligible for extended hours treatment (8). Patients vary in a number of respects that could affect both their willingness to undergo extended hours treatment and the potential socioeconomic costs to them of doing so. As examples, patients who are still employed full or part time, patients who are still actively involved in their communities (e.g., social groups, religious participation, and volunteer organizations), and patients whose leisure and other daily activities are less affected by any health declines may be less willing. Such patients would also be more likely to report declines in quality of life if they underwent extended hours dialysis during daytime hours. (The psychosocial effect of undergoing extended hours dialysis may be attenuated when treatments are administered overnight.) Incidentally, such socially engaged patients may also have been less willing to participate in the trial reported by Smyth et al. (5). Indeed, it is not clear how generalizable the study’s findings are, because we have limited information about patients who declined to participate in this trial and the protocols followed to recruit patients. Future studies should give fuller consideration to the preferences and psychosocial characteristics of patients to clarify for which patients the treatment approach would be most—or least—appropriate.
Finally, we note that any future, broader implementation of extended hours hemodialysis protocols would entail confronting an array of logistical considerations around scheduling, clinical staff handoffs, and coordination as well as the physical arrangement of patients undergoing treatment (e.g., a designated bay of dialysis station chairs for use primarily by patients undergoing extended hours hemodialysis treatment). Each of these factors may have implications for patient wellbeing, although again, nocturnal treatment programs can alleviate some of these issues as well, taking place at an hour when the dialysis facility is otherwise much less occupied. Still, before any such protocols can be implemented with the justification of a robust evidence basis, some further research is needed.
Dr. Lea and Dr. Wilks have nothing to disclose.
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