Protecting Kidney Patients' Hearts: Has the Time Come to Rethink Dialysis Treatment Cadence?

Franklin W. Maddux, MD, FACP

Cardiac disease prevention and management is one of the most important clinical targets in patients receiving maintenance dialysis. Cardiac disease is a leading cause of death in people receiving dialysis, and premature cardiomyopathy and the associated higher risk of fatal cardiac arrhythmias are well recognized. Cardiac dysfunction may result from subtle persistent volume overload and increased intracardiac pressures. Despite this understanding, the field has not made significant enough advances in the prevention of cardiovascular complications.

One of the areas for opportunities to advance care is the frequency of hemodialysis. Standard thrice-weekly hemodialysis represents the dominant cadence of current dialysis delivery throughout the world. The vast majority of patients receiving in-center dialysis are treated three times per week, resulting in a pattern of long interdialytic intervals (LIDIs) of 72 hours without dialysis each week. This traditional pattern predestines a long interdialytic interval (LIDI) every week for patients receiving in-center hemodialysis.

What are the risks to patients without residual kidney function that can be attributed to the LIDI? Two-thirds of patients have demonstrated cardiac rhythm disturbances following a missed treatment or the LIDI. In a large study in 2011, the investigators found that the first hemodialysis treatment after the LIDI is associated with increased cardiovascular-related hospital admissions and elevated death rates.2 They concluded that “the long interdialytic interval is a time of heightened risk among hemodialysis patients.” A Dialysis Outcomes and Practice Pattern Study suggests the dialysis treatment schedule affects day-of-week mortality.3 In data from the United States, Japan, and Europe, in-center prevalent hemodialysis patients treated on Monday, Wednesday, and Friday have a higher risk of death on Mondays, and patients treated on Tuesday, Thursday, and Saturday have a higher risk of death on Tuesdays (Figure 1).

FIGURE 1  |  In-center hemodialysis treatment schedule and mortality risk

These findings highlight the serious risks associated with the LIDI. Complications associated with the LIDI also include exacerbation of volume accumulation and cardiac re-modeling.4 In addition, the first hemodialysis treatment following the LIDI is more likely to require a higher ultrafiltration rate. Higher ultrafiltration rates during hemodialysis have received significant attention as the understanding of the deleterious consequences, including myocardial stunning, have advanced.

As kidney care evolves to become more personalized and precise for every person, cardiovascular health and prevention of chronic volume overload and the associated long-term complications must be addressed. The field must advance to provide a treatment frequency that aligns with physiologic needs. Instead of focusing on treatment of cardiac complications, it is necessary to proactively prevent or slow the progression of cardiac disease and focus on cardiovascular health. It must be considered whether both active monitoring for rhythm disturbances and understanding the nervous system’s input into arrythmias need consideration.

Examining how best to personalize the hemodialysis treatment frequency for each person’s physiologic needs — with the prescription informed by residual kidney function, blood pressure control, and cardiovascular treatment goals — is critical. Such an endeavor will require the collaboration of stakeholders across the entire healthcare delivery system, from patients to providers to payors and policy makers, and has the potential to make a lasting impact on advanced kidney disease care worldwide. 

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References

1. Roy-Chaudhury P, Tumlin JA, Koplan BA, et al. Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle. Kidney Int 2018 Apr;93(4):941-51. doi: 10.1016/j.kint.2017.11.019.
2. Foley RN, Gilbertson DT, Murray T, Collins AJ. Long interdialytic interval and mortality among patients receiving hemodialysis. N Engl J Med 2011 Sep 22;365(12):1099-1107. doi:10.1056/NEJMoa1103313.
3. Zhang H, Schaubel DE, Kalbfleisch JD, et al. Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality. Kidney Int 2012 Jun;81(11):1108-15. doi:10.1038/ki.2011.481.
4. Rhee CM. Serum potassium and the long interdialytic interval: minding the gap. Am J Kidney Dis 2017 Jul;70(1):4-7. doi: 10.1053/j.ajkd.2017.04.007. PMID: 28646982.