INTRODUCTION — The first successful use of short daily or "quotidian" hemodialysis was first reported by DePalma in 1969 [1,2]. This approach was based upon the premise that improved patient outcomes, compared with conventional three times per week hemodialysis, would occur with a dialysis schedule that consisted of the same number of hours of dialysis per week but delivered over twice as many sessions. More specifically, this schedule consists of daily hemodialysis (five to seven days per week) provided for a duration of 1.5 to 3 or more hours per session.
Initial attempts to popularize daily dialysis in the United States were thwarted by financial and logistical issues. This led to a decline in its use both in the home and in-center settings.
Over the last decade, however, there has been a resurgence in the use of daily dialysis, with several studies emerging from the United States and Europe showing improvements in various physiologic and clinical outcomes. In the wake of the Hemodialysis (HEMO) study, which found no overall survival benefit with high- versus low-flux hemodialysis, attention turned from increasing per-session small solute clearance to altering treatment frequency and/or duration [3,4].
Increasing availability and acceptability of daily home hemodialysis (HHD) has contributed to the recent increase in home dialysis use in the United States and other high-income countries. Between 2009 and 2019, the cumulative incidence of home dialysis within the first year of dialysis initiation increased from 10.5 to 18 percent, with a point-prevalent rate of 13 percent for home dialysis among all patients on kidney replacement therapy. Although peritoneal dialysis was the dominant form of home dialysis (11.2 percent), among the 1.9 percent of patients on home hemodialysis in the United States in 2019, 39.1 percent were prescribed at least 3.5 and 38 percent at least 5 sessions per week, making more frequent dialysis the most common form of HHD in the United States, mainly using a low dialysate volume approach (NxStage).
Daily dialysis has also been proposed as a rescue therapy and in the intensive care unit (ICU) setting [5,6] (see "Prolonged intermittent kidney replacement therapy"). Short daily hemofiltration and hemodiafiltration have also been introduced, being used both in center and at home [7,8]. The 2015 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines suggest offering in-center short daily hemodialysis as an alternative to conventional hemodialysis [9].
This topic review will discuss short daily hemodialysis. A review of long daily or nocturnal hemodialysis is presented separately. (See "Technical aspects of nocturnal hemodialysis".)
A review of home hemodialysis using a low-dialysate volume approach (ie, NxStage) is discussed elsewhere. (See "Short daily home hemodialysis: The low dialysate volume approach".)
OVERVIEW OF RATIONALE — The rationale for short daily hemodialysis is based upon a strategy that is proposed to enhance both dialysis efficiency and hemodynamic stability.
●Improved dialysis efficiency – The exponential decrease in the serum concentration of small molecules, such as urea, during hemodialysis leads to dissipation of the blood-to-dialysate gradient and to reduced efficiency of small molecule removal over time [10]. With short daily dialysis, shortening the dialysis time while increasing the frequency of dialysis allows more time to be spent dialyzing against higher uremic solute concentration gradients. This enhances the efficiency of solute removal. Ultimately, a new steady state with lower peak but higher trough solute concentrations is achieved.
●Improved hemodynamic stability – More frequent dialysis allows for less interdialytic fluid accumulation. This is likely to improve hemodynamic stability during dialysis, with increased potential for normalizing the extracellular fluid volume (ECFV).
MEASURES OF ADEQUACY — Traditional urea kinetic modeling, as validated for conventional (three times weekly) hemodialysis, cannot be directly applied to the assessment of dialysis adequacy with frequent (short daily or nocturnal) dialysis regimens. (See "Prescribing and assessing adequate hemodialysis" and "Technical aspects of nocturnal hemodialysis".)
The need for a universal dose measure applicable to all modalities that may correlate with patient outcomes has therefore led to standard weekly Kt/V (stdKt/V) being the measure of adequacy. The stdKt/V is more widely utilized than other methods and is calculated based upon the midweek predialysis urea rather than the time-averaged concentration (TAC) of urea [11]. The minimum recommended dialysis dose, which follows the current Dialysis Outcomes Quality Initiative (DOQI) guidelines, is a stdKt/V value of approximately 2 per week for all dialysis methods. A weekly stdKt/V of 2 is provided by a daily dose with an equilibrated Kt/V (eKt/V) of 0.38 (less than one-half of the required dose of 1.05 with conventional hemodialysis).
Compared with conventional dialysis, however, the same number of hours per week of daily dialysis results in lower predialysis urea values. Thus, current daily short hemodialysis provides a higher stdKt/V of approximately 3 [12,13].
How well any of these measures correlate with clinical outcomes is currently unclear.
PRACTICAL ASPECTS OF DAILY HEMODIALYSIS DELIVERY — General features of and prerequisites for a home dialysis program are discussed separately (see "Home hemodialysis (HHD): Establishment of a program") [14]. The following section elaborates on some of the technical and logistical details of daily dialysis delivery with a focus on the home setting.
Patient recruitment and selection — To date, there are no evidence-based recommendations to guide patient selection for home daily dialysis. In practice environments where resources limit its use, daily dialysis should be prescribed on the basis of need, such as the management of refractory uremic complications, fluid overload, resistant hypertension, or intradialytic hypotension.
Until large-scale comparative studies are available, the selection of nocturnal versus short daily dialysis should largely be dictated by availability and patient preference, although patients with particularly difficult to manage hyperphosphatemia clearly benefit more from the longer treatment time conferred by nocturnal therapy. Where resources are not limited and in the absence of contraindications, patient willingness remains the primary criterion for selection for daily dialysis. Significant barriers to home-based therapy include decreased compliance, cognitive ability, visual acuity, and/or motor skills and/or a lack of an assistant.
Center-based daily hemodialysis may be reserved for those in greatest medical need or for volunteers ardently seeking improved quality of life or functional status. Patients with high levels of comorbidity and those with hemodynamic instability or seizure disorders are better suited to the supervised in-center environment.
For center-based therapy, patient proximity to the dialysis unit and availability of transportation may be important limiting factors. However, this does not mean that the use of daily dialysis as a form of "rescue therapy" for medical reasons cannot be considered in patients with geographic limitations (if even for shorter periods of time).
Training and education for a home daily hemodialysis patient — Training usually requires a full-time six-week commitment, although two weeks can be sufficient for a patient with self-care experience. Training focuses on the use of the dialysis machine, troubleshooting alarms, adjusting treatment parameters (including dialysate composition), dealing with emergencies (eg, air embolism, accidental disconnection from the blood circuit), and proper vascular access cannulation/connection technique. It is also important to include machine and water treatment maintenance, supply management, medication self-administration, and laboratory sampling in the training schedule [15].
Patient training for daily hemodialysis was compared with those undergoing conventional hemodialysis in the London Daily/Nocturnal Hemodialysis Study of 11, 12, and 22 patients undergoing short daily, nocturnal, and conventional hemodialysis, respectively [15]. The average patient training period was approximately 17 days, with patients using native arteriovenous fistulae (AVF), grafts, or central catheters.
Vascular access — Native AVF, synthetic grafts, and long-term central venous catheters (CVCs) are all acceptable for use in daily hemodialysis, with the same order of preference as for conventional dialysis. Similarly, needles suitable for conventional dialysis can be used for daily dialysis.
Patient comfort and AVF longevity may be increased by using the buttonhole technique, which involves re-cannulation of the same two or three sites on a rotating basis [16-18]. Using this method, the needle/cannula is inserted through exactly the same hole at the same angle and depth of penetration [18-20]. After 8 to 10 cannulations (or 12 to 14 in diabetic patients), an epithelialized track develops that allows the use of blunt needles [18].
Buttonhole cannulation without the use of local mupirocin can be associated with Staphylococcus aureus bacteremia, often leading to life-threatening metastatic infections. The risk of infection was examined in the following studies:
●A randomized trial compared 140 conventional hemodialysis patients assigned to either the buttonhole technique or to conventional "rope-ladder" needling [21]. At eight weeks, the rate of localized infection was higher among patients assigned to the buttonhole technique compared with conventional needling (50 versus 22.4 per 1000, respectively). There was one episode of S. aureus bacteremia at eight weeks and two more episodes after the study ended but within 12 months in the group utilizing the buttonhole technique versus none in the conventional needling group. At 12 months, the number of needling site abscesses requiring intravenous (IV) antibiotics was higher in the buttonhole group versus the conventional needling group (nine versus zero, respectively). The degree to which these data from conventional hemodialysis patients may be extrapolated to nocturnal daily hemodialysis or self-cannulating patients is not clear [22]. (See "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention", section on 'Standard versus buttonhole technique'.)
●A retrospective review analysis compared the buttonhole technique with rope-ladder cannulation among 90 consecutive home hemodialysis patients [23]. Over 3765 AVF-months, there were 17 systemic infections attributed to fistula infections. Compared with rope-ladder cannulation, the buttonhole technique was associated with a higher rate of total fistula infections (incidence rate ratio [IRR] 3.85, 95% CI 1.66-12.77) but not systemic infections. Loss of the fistula or requirement for surgical intervention was not different between the groups, although interventions by radiology were not included in the analysis [24].
An accompanying systematic review also found an increased risk of infections associated with buttonhole technique compared with other techniques in four randomized trials (relative risk [RR] 3.34, 95% CI 0.91-12.20), as well as in observational studies.
As a result of the increased risk of infection, avoidance of buttonhole cannulation has been advocated by some experts. We have not seen any cases of S. aureus bacteremia in our center since adopting mupirocin prophylaxis. Most centers do not practice the buttonhole technique for facility-based dialysis.
The buttonhole technique may be associated with fewer thrombotic complications. In the Frequent Hemodialysis Network (FHN) trial, in which 245 patients were randomly assigned to receive in-center six days per week hemodialysis or conventional three days per week hemodialysis, compared with the rope-ladder technique, the buttonhole technique was associated with longer intervals between access-related events (hazard ratio [HR] 0.44, 95% CI 0.20-0.97) [25]. This benefit was driven mostly by a reduction in thrombotic episodes. The buttonhole technique may also improve fistula survival among patients undergoing conventional hemodialysis [26]. (See "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention", section on 'Standard versus buttonhole technique'.)
Irrespective of technique (ie, buttonhole versus rope ladder), more frequent cannulation may lead to more frequent access-related complications, and regular clinical assessment of the AV access should be part of routine follow-up for patients on hemodialysis in any care setting. (See 'Vascular access' below.)
Equipment and technical aspects — It is important to establish standardized technical requirements that incorporate the assessment of the patient's home and implications for installation planning and home renovations, if required. The dialysis machines approved for home hemodialysis in the United States include the Fresenius 2008@Home, NxStage System One and One S, and Outset Medical Tablo [14].
The proliferation of home hemodialysis has led to the production of dialysis machines specifically designed for home use. In general, these machines should be simple to use, compact, and quiet, with easily accessible controls. A review of the different dialysis machines currently available for the home can be found elsewhere. (See "Choosing home hemodialysis for end-stage kidney disease".)
Appropriate water treatment must be provided to the home. Initial water samples for chemical content and bacteria are needed to determine water treatment requirements. These may be different for rural patients on well water versus those in an urban area on municipal water. (See "Assuring water quality for hemodialysis", section on 'Design of systems for home hemodialysis'.)
There are essentially two types of water treatment systems: reverse osmosis (RO) and deionization (DI) systems. The choice of either a RO or DI water system should be determined by a program policy that factors in capital equipment costs, operating costs, water system support and service, patient training responsibility, and system safety and reliability. Most centers use RO water systems as they are less costly to operate after the initial higher cost of purchase.
A suitable RO system for home use must be small and quiet and must be compatible with the patient's dialysis machine. The configuration of the patient's home should be considered when choosing a purification system. For daily dialysis, the water treatment system can be located in the room adjacent to the dialysis machine as noise levels may not be so important (as compared with nocturnal dialysis, where sleep can be affected by noise).
With respect to in-center dialysis, the ideal dialysis equipment should provide quick patient turnaround to help with scheduling, although any equipment can be used. Having additional machines on hand can reduce down time between treatments by enabling setup and priming to occur asynchronously.
Additional details of the technical requirements of home hemodialysis programs with full references can be found elsewhere [27].
Dialyzer selection — Membrane selection for daily hemodialysis is the same as for conventional hemodialysis, and synthetic, high-flux membranes are typically used.
Dialysis prescription and dose monitoring — As previously mentioned, the optimal method of prescribing and monitoring the dose of daily hemodialysis regimens is not established. Some method of dose quantification is necessary to guide individual patient prescriptions, to monitor adequate dialysis delivery, and to allow patient outcome comparisons between the various dialysis regimens.
Based upon mathematical modeling, a per-session equilibrated Kt/V (eKt/V) of 0.37 (single-pool Kt/V [spKt/V] of 0.53 to 0.56) delivered using a short daily hemodialysis regimen is roughly equivalent to conventional hemodialysis with a per-session eKt/V of 1.05 [28]. This should be considered a minimum acceptable dose when using short daily dialysis.
In our opinion, however, a weekly standardized Kt/V (stdKt/V) target of 3 should be sought, as was achieved in the London Daily/Nocturnal Study [12]. This dose was associated with improvements in a number of physiologic parameters (as noted in the next section) and allows for a margin of safety in case the prescribed dose is not fully delivered. This is equivalent to a weekly spKt/V of 5.6, a per-session spKt/V of 0.93, or a sessional eKt/V of 0.82.
Modeling indicates that this target is likely to be achievable with a 2.5 hour, six day per week regimen in 95 percent of patients [29]. In the London Study, the delivered dose was achieved using high-flux, large surface area dialyzers (eg, F80, Optiflux 160 or 200) with dialyzer blood flow rates of 400 to 500 mL/min and a dialysate flow rate of 800 mL/min [12,30].
The value of urea clearance in daily hemodialysis has not been clearly established. Other markers, such as phosphorous clearance, may be important as well. In one study, treatment times of three hours per session were associated with improvements in phosphate levels and calcium-phosphorous product [31], which are not consistently seen with shorter treatment times [32].
As more rigorous studies are conducted in this area, ideal clearance targets for daily hemodialysis will hopefully emerge.
Dialysate composition — The dialysate composition used with daily hemodialysis in the manner described above is generally not different from that used with conventional hemodialysis, with the exception of the machines using the low dialysate volume approach (NxStage). The composition of the dialysate is as follows:
●Sodium – 135 to 140 mEq/L
●Potassium – 2 to 3 mEq/L
●Bicarbonate – 35 to 40 mEq/L
●Calcium – 2.5 to 3.5 mEq/L
Patient monitoring and safety — Daily home hemodialysis does not require remote monitoring, since treatments are generally carried out during the daytime and always with the patient awake. Security devices such as enuresis alarms and connector clamps are also generally not needed. Safety issues associated with nocturnal hemodialysis are discussed elsewhere. (See "Technical aspects of nocturnal hemodialysis", section on 'Safety'.)
OUTCOMES — Multiple observational studies and one randomized trial have shown that more frequent dialysis improves selected outcomes. A benefit on survival has not been shown, although a follow-up for a median of 3.6 years after the completion of the Frequent Hemodialysis Network (FHN) showed a survival advantage of the daily hemodialysis group versus controls (hazard ratio [HR] 0.54, CI 0.31-0.93) [33].
Frequent Hemodialysis Network (FHN) daily trial — The FHN trial was a multicenter, randomized trial that included 245 patients assigned to either frequent hemodialysis (six times weekly) or conventional hemodialysis [34]. Two primary composite outcomes were determined at one year, including death or one-year change from baseline in left ventricular (LV) mass, as assessed by cardiac resonance imaging, and death or one-year change in physical health, as assessed by a RAND heath survey. Both composite outcomes showed significant benefit to the frequent-dialysis group compared with the conventional-dialysis group (HR 0.61, 95% CI, 0.46-0.82 for death or change in LV mass and HR 0.70, 95% CI, 0.53-0.92 for death or change in physical health).
This study also demonstrated benefits in predetermined secondary outcomes to the frequent dialysis group, such as a decrease in LV mass, improved blood pressure control, and phosphate balance but not on cognitive performance, depression, serum albumin concentration, or use of erythropoiesis-stimulating agents (ESAs). Posthoc analyses, however, suggested that frequent in-center dialysis led to improved self-reported general mental health [35] and aspects of health-related quality of life including a shorter recovery time after a dialysis session [35,36]. Frequent dialysis reduced LV end-diastolic volume, LV end-systolic volume, and right ventricular (RV) end-diastolic volume but did not affect the ratio between LV mass/LV end-diastolic volume, which is a marker for LV remodelling [37].
Observational data — Several hundred observational studies have evaluated the various potential benefits and risks of daily hemodialysis. Most have used patients as their own controls, using pre-post comparisons as opposed to parallel control groups. While these studies have been limited by the usual methodologic problems encountered in observational research, they have been instrumental in shaping the way daily hemodialysis is delivered and have shown improvements in a number of important secondary outcomes.
Clearances
Urea — A discussion of clearances of urea with short daily hemodialysis is presented above. (See 'Dialysis prescription and dose monitoring' above and 'Measures of adequacy' above.)
Middle molecules — In general, middle-molecule removal is determined by the dialyzer permeability, the presence of convection, protein binding, and dialysis duration. Given that daily dialysis results in more frequent solute level equilibration with less rebound, this technique provides higher middle-molecule removal than with conventional hemodialysis, although the reported increase varies by the method of calculation.
●The increased clearance is quantitatively modest if the measurement is based on the time-averaged concentration (TAC) of the solute (as in the calculation of equivalent renal urea clearance [EKR]) [38].
●The increased clearance is significant when it is based upon the predialysis concentration of the solute (as in the case of standardized Kt/V [stdKt/V]) [39].
By comparison, middle-molecule removal increases significantly by daily nocturnal hemodialysis independent of the calculation method since both time and frequency increase [38-40].
The serum levels of advanced glycosylation end products also decrease upon conversion from conventional to short (and long nocturnal) hemodialysis [41,42]. However, middle-molecule clearance is better with daily hemofiltration than with daily short hemodialysis [43]. A discussion of middle molecules can be found elsewhere. (See "Uremic toxins".)
Protein-bound molecules — In general, protein-bound molecules are not easily removed by dialysis. Although an earlier study suggested that some protein-bound molecules (eg, indole-3-acetic acid, indoxyl sulfate) may be more efficiently cleared with daily, as compared with conventional, hemodialysis [41], the FHN trial showed a limited reduction in plasma levels of such uremic solutes with more intensive hemodialysis [44]. (See "Uremic toxins".)
Phosphate — Several studies have shown that short daily hemodialysis improves phosphate balance [31,34,45]. In the FHN daily trial, at one year, compared with the conventional dialysis group, the frequent dialysis group had a lower predialysis serum phosphorus (5.24 versus 5.65, respectively) [34] and a 1.35 g/day reduction in the required equivalent phosphate binder dose [46].
Quality of life — Health-related quality of life has been studied using a number of validated instruments. Studies in this area have been mostly positive, with multiple studies showing increases in short form-36 (SF-36) physical or mental component scores [47-53]. One study, for example, demonstrated a significant improvement in utility score (from 0.34 to 0.84), as measured using the time trade-off method after converting from conventional hemodialysis to daily hemodialysis [48]. However, no difference in utility was observed when the Health Utilities Index (HUI) was used.
A variety of other instruments have shown improvements in or disappearance of uremia and dialysis-related symptoms [47,48,51,54-57].
In a prospective cohort study (FREEDOM study), among 154 participants (90 percent of whom converted from in-center hemodialysis) who completed an SF-36 health survey at enrollment and at 12 months, there was a sustained improvement in the physical- and mental-component summary scores, as well as in individual domains of the survey [53]. The number of individuals who achieved a physical-component score comparable with the general population more than doubled.
Among 94 patients with disturbed sleep and/or restless leg syndrome who were included in the FREEDOM study, short daily hemodialysis resulted in a sustained improvement in restless legs symptoms as assessed by the International Restless Leg Syndrome (IRLS) Study Group rating scale [58]. However, the percentage of patients prescribed medication for restless leg syndrome did not decrease.
After adjusting for restless legs syndrome and the use of related medications, daily hemodialysis was also associated with an improvement in sleep adequacy and disturbances.
Cardiovascular outcomes — Improvements in blood pressure control have been observed with short daily hemodialysis [5,47,54,57,59-62]. These include decreases in systolic, diastolic, and/or mean predialysis arterial pressures, with concomitant reductions in blood pressure medication doses [5,34,54,63,64]. In the FHN daily trial, the frequent dialysis group had a lower average predialysis systolic blood pressure compared with the conventional dialysis group at one year (137 versus 147 mmHg, respectively) [34].
Improvements in blood pressure control also correlate with reductions in LV mass. This was first illustrated in a randomized crossover study of 12 patients in which LV mass fell after six months with daily short hemodialysis (148.7±59.7 g/m2 during conventional hemodialysis to 120.1±60.4 g/m2) [60]. A reduction in LV mass was also shown in the FHN trial; the mean LV mass decreased by 16.4 g in frequent dialysis patients over one year compared with 2.6 g in the controls [34]. Regression of cardiac hypertrophy [45], a decrease in the markers of inflammation (C-reactive protein [CRP]) [45], and a reduction in regional wall motion abnormalities [65] have all been associated with more frequent hemodialysis.
A concomitant significant reduction in extracellular fluid volume (as measured by bioimpedance spectroscopy) from 52.7±11.4 percent of total body water to 47.6±7.5 percent was also observed. Similarly, the London Daily/Nocturnal Hemodialysis Study found that extracellular fluid volume was lower in daily hemodialysis patients than in matched cohorts receiving conventional hemodialysis [62].
All of these studies also demonstrated improved blood pressure control [60,62]. This suggests that some of the beneficial antihypertensive effect of daily hemodialysis is related to improved extracellular fluid volume control [66].
Despite these encouraging findings, the effect of daily hemodialysis on cardiovascular morbidity and mortality has not yet been described in an adequately powered study.
Anemia and erythropoietin dosing — The effect of daily hemodialysis on erythropoiesis is uncertain. Some studies report increases in hemoglobin or hematocrit [54,55,59,67], while others have found little change [5,47,60,68,69]. The accurate interpretation of these findings is complicated by the potential for increased surveillance by home dialysis programs, with more aggressive treatment with ESAs and iron and/or more prompt investigation and treatment of iron deficiency in this setting.
At least three cohorts have required significantly less use of ESAs after converting to daily hemodialysis [5,47,56]. However, most studies have failed to show any significant change in ESA utilization [34]. Increased blood loss through the dialysis circuit resulting in iron deficiency may theoretically mask the potential pro-erythropoietic effects of daily dialysis.
Nutritional effects — Daily dialysis may impact a number of nutritional indices. Daily in-center hemodialysis has been used as a rescue therapy for patients with severe malnutrition complicating uremia [5,70], with patients generally reporting increased appetite after switching from conventional to daily hemodialysis. One study, for example, showed an increase in protein intake by 25 percent [70].
The effects on serum albumin, normalized protein equivalent of nitrogen appearance (nPNA), and dry body weight have been variable, with many studies showing improvements in these parameters and others showing no significant change. Statistical power may have been an issue in some of these negative studies. A secondary analysis of data from the FHN trial cited above showed no difference between patients undergoing frequent versus conventional hemodialysis in serum albumin, protein catabolic rate, or lean body mass [71]. Frequent dialysis was associated with an increase in body weight that was probably due to increased fat.
Hospitalizations — Some studies have found a reduction in hospital admissions with daily hemodialysis [5,72]. In one study of 42 patients with a high burden of comorbidity, there was a significant reduction in hospital days from 12.2 patient/year on conventional hemodialysis to 8 patient/year on daily hemodialysis [5]. This was associated with a 40 percent reduction in hospital admissions per patient per year.
However, no study has demonstrated significant differences in hospitalization rates associated with daily hemodialysis, even when comorbidities are similar to the general hemodialysis patient population. In addition, most studies have lacked adequate statistical power to study the effect of daily hemodialysis on hospitalization rates.
A nationally representative cohort of 27,430 patients in Canada experienced 111,748 hospitalization episodes over nine years. The probability of a Monday/Tuesday admission was lower for frequent home hemodialysis (HHD) (odds ratio [OR] 0.89, 95% CI 0.81-0.97) and peritoneal dialysis (OR 0.95, 95% CI 0.93-0.97) compared with in-center hemodialysis [73].
While existing data are encouraging, larger studies with longer periods of follow-up are needed to study this important outcome.
Vascular access — More frequent vascular access cannulation required for daily hemodialysis may result in decreased access survival. This issue was addressed in the FHN daily trial, in which the primary vascular outcome was time to first access event (including repair, loss of access, or access-related hospitalization), and the secondary vascular outcome was the time to all repairs and time to all losses [34]. Among all participants (including 198 with a fistula or graft and 47 with a tunneled catheter), the risk for a first access event was higher in the daily group compared with the conventional group (33 repairs and 15 losses versus 17 repairs, 11 losses, and 1 hospitalization, respectively, HR 1.76, 95% CI 1.11–2.79). The increase in risk of a first access event associated with daily dialysis was even greater when patients with a tunneled catheter were excluded from the analysis (HR 1.90, 95% CI 1.1-3.25). Overall, daily dialysis was associated with more access repairs, and 55 percent of all repairs involved thrombectomy [25]. The risk of permanent access loss and of infection did not differ between the groups. These outcomes should be considered when patients are weighing dialysis options [74].
Other studies have reported access survival comparable to that seen with conventional hemodialysis [72,75]. It is possible that more uniform use of the buttonhole method of cannulating arteriovenous fistulae (AVF) may reduce the number of thrombotic complications associated with daily hemodialysis [76], although infectious complications may be more frequent with this technique [21]. This issue is discussed above. (See 'Vascular access' above.)
We agree with the 2015 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines that patients who are considering short daily hemodialysis be informed about the possibility of an increase in vascular procedures with this therapy [9].
Cost — The few analyses of the economic costs associated with more frequent hemodialysis treatment have demonstrated that overall simulated annual direct healthcare costs are likely to be lower for daily dialysis protocols compared with conventional hemodialysis [77,78]. As an example, higher costs for dialysis consumables are offset by lower costs for hospitalizations and medications. In addition, should the patient receive the therapy at home, an advantage is realized with reduced labor costs that more than offset the capital cost of equipment and renovations provided that the patient remains at home for at least 24 months [79].
While daily dialysis regimens may be economically attractive from the societal perspective, it may not be appealing from the prospective of the dialysis facility, as the expected cost savings are often realized at other levels of the health care system. Thus, the economics of daily dialysis within current funding mechanisms represents a barrier to widespread adoption of these modalities.
Larger and better controlled studies are needed to provide additional proof that more frequent hemodialysis can improve clinical parameters and at the same time reduce total health care costs in the long run. A detailed review of the published information regarding the economics of daily hemodialysis can be found elsewhere [80,81].
Survival — As noted above, a follow-up for a median of 3.6 years after the completion of the FHN trial showed a survival advantage of the daily hemodialysis group versus controls (HR 0.54, CI 0.31-0.93) [33].
There are conflicting data from retrospective and observational studies, although most suggest a benefit [82-84]. In the largest observational study, 1873 home hemodialysis patients were compared with 9365 matched in-center patients selected from the United States Renal Data System (USRDS) database [85]. The incidence of death was lower among home hemodialysis patients (19.2 versus 21.7 percent among in-center patients, HR 0.87, 95% CI 0.78-0.97).
In another retrospective study, 338 patients who were receiving intensive home hemodialysis (mean of 4.8 sessions per week, with a mean treatment time of 7.4 hours per session) were compared with 1338 propensity-matched patients on conventional hemodialysis (mean of three sessions per week, with a mean treatment time of 7.4 hours per session) [84]. Mortality was lower among patients on intensive hemodialysis (13 percent versus 21 percent for control patients on conventional hemodialysis).
While both studies used rigorous statistical methods and adjusted for most prognostic variables, unmeasured confounders may have contributed to the differences in outcomes. Thus, the association between more frequent hemodialysis and survival requires confirmation in larger clinical trials.
SUMMARY AND RECOMMENDATIONS
●Rationale – Short daily or "quotidian" hemodialysis consists of daily hemodialysis (five to seven days per week) provided for a duration of 1.5 to 2.5 hours per session. The rationale for this strategy is based upon the premise that improved patient outcomes, compared with conventional three times per week hemodialysis, may occur due to improved dialysis efficiency and hemodynamic stability. (See 'Introduction' above and 'Overview of rationale' above.)
●Practical aspects of daily hemodialysis delivery
•Patient recruitment and selection – In practice environments where resources limit its use, daily hemodialysis should be prescribed on the basis of need, such as the management of refractory uremic complications, fluid overload, or intractable hypertension. Until large-scale comparative studies are available, the selection of nocturnal versus short daily hemodialysis should largely be dictated by availability and patient preference. (See 'Patient recruitment and selection' above.)
•Training and education – Training a home daily hemodialysis patient usually requires a full-time, six-week commitment, although two weeks can be sufficient for a patient with self-care experience. Newer dialysis machines may require shorter training times. (See 'Training and education for a home daily hemodialysis patient' above.)
•Vascular access – Native arteriovenous fistulae (AVF), synthetic grafts, and long-term central venous catheters (CVCs) are all acceptable for use in daily hemodialysis. (See 'Vascular access' above.)
•Equipment and technical aspects – Although the choice of hemodialysis equipment is wide, it is still based upon the designs of hemodialysis machines that are used in center. Appropriate water treatment must be provided to the home. (See 'Equipment and technical aspects' above.)
•Dialysis prescription – A weekly standardized Kt/V (stdKt/V) target of 3 should be sought, which is associated with improvements in a number of physiologic parameters. Modeling indicates that this target is likely to be achievable with a 2.5 hour, six day per week regimen using high-flux, large surface area dialyzers with dialyzer blood flow rates of 400 to 500 mL/min and a dialysate flow rate of 800 mL/min. (See 'Dialysis prescription and dose monitoring' above.)
•Dialysate composition – The dialysate composition used with daily hemodialysis is generally not different from that used with conventional hemodialysis. (See 'Dialysate composition' above.)
•Patient monitoring – Daily hemodialysis does not require remote monitoring, and security devices such as enuresis alarms and connector clamps are also generally not needed. (See 'Patient monitoring and safety' above.)
●Outcomes
•Compared with conventional hemodialysis, short daily hemodialysis is associated with increased clearances of urea (based upon stdKt/V), middle molecules, and protein-bound molecules. It may also be associated with a better quality of life, blood pressure control, improved appetite, and decreased rate of hospitalizations. (See 'Clearances' above.)
•The effect of daily hemodialysis on erythropoiesis is uncertain, with increases in hemoglobin levels being inconsistent. (See 'Anemia and erythropoietin dosing' above.)
•Overall simulated annual direct health care costs are likely to be lower for daily hemodialysis protocols compared with conventional hemodialysis. (See 'Cost' above.)
