Year: 2010
Type: letter
Abstract: To the Editor: Covic et al. recently formulated and published their clinical advice on education of end-stage renal disease (ESRD) patients on selection of dialysis modality on behalf of the European Renal Best Practice Advisory Board [1]. They state that there is currently insufficient evidence to support one modality above the other and that the initial modality choice should be made by the well-informed patient, whether it is conventional in-centre or home haemodialysis, short daily haemodialysis (SDHD), nocturnal in-centre haemodialysis (NHD), nocturnal home haemodialysis (NHHD) or peritoneal dialysis. However, increasing evidence is available that intensive haemodialysis (SDHD, NHD and NHHD) offers significant improvement of several clinical (e.g. blood pressure, left ventricular hypertrophy, coronary calcification, sleep apnoea, quality of life, fertility), biochemical (e.g. phosphate control, anaemia) and biological (e.g. endothelial function, inflammation) parameters. An extensive overview of the observed benefits of intensive haemodialysis was recently published by Perl and Chan [2]. Moreover, observational studies have shown that the survival of intensive haemodialysis patients is better than conventional haemodialysis patients and even comparable to patients who underwent deceased donor kidney transplantation [3–5]. Recipients of living donor kidney transplantation still demonstrate the best survival. These studies definitely have a number of limitations, but the type of study is probably the best we can get because randomized prospective clinical trials between haemodialysis and transplantation and between different dialysis modalities may not be feasible due to the decisive role of social factors in the final dialysis modality choice. Based on the demonstrated superior results of intensive haemodialysis on clinical, biochemical and biological parameters and supported by the possible improved survival of these patients, we are convinced that ESRD patients who require renal replacement therapy (RRT) should be informed about intensive haemodialysis as the best available modality (‘intensive haemodialysis first’), at least if their social circumstances allow this type of treatment. This strategy is already common practice in some parts of the world (e.g. Australia). Evidently, living donor kidney transplantation remains the gold standard since it offers the best survival to ESRD patients, but to our opinion, intensive haemodialysis has to be considered as the optimal bridging modality awaiting transplantation. Certainly, in the current era of long waiting time for deceased donor kidney transplantation, ESRD patients who require RRT deserve the modality of dialysis which has the best clinical, biochemical and biological effects and which possibly offers the best survival. This will also allow them to present themselves for kidney transplantation in the most optimal clinical condition which will in itself reduce transplantation-associated morbidity and mortality. Furthermore, given the result of observational studies, ESRD patients who may never be transplanted (e.g. because of a high degree of immunological sensitization) may have, although not supported by evidence, a survival benefit if they are treated with intensive haemodialysis compared with ESRD patients treated with conventional haemodialysis. Conflict of interest statement. None declared.
DOI: 10.1093/ndt/gfq365
Language: English
Subfield: Nephrology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2037514801