CSN Guideline
Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis

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Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.

Section snippets

Background

Longer and more frequent (“intensive”) hemodialysis has emerged as desirable alternative treatment strategies for patients with end-stage renal disease (ESRD). Although there is significant variability in prescription practices, 3 pragmatically defined categories encompass the majority of intensive dialysis prescriptions used in Canada and elsewhere: short daily (<3.0 hours, 5-7 days per week), long (often nocturnal; ≥5.5 hours, 3-4 sessions per week), and long-frequent (usually nocturnal; ≥5.5

Purpose of the Guidelines

Our objective was to develop a clinically useful guideline (summarized in Box 1) to assist physicians and allied health care practitioners in the management of patients with ESRD who have chosen more intensive hemodialysis as their treatment modality; it is not intended to replace clinical judgment.

Guideline Panel Composition

To form the guideline panel (Box 2), physicians with an established clinical interest in intensive hemodialysis prescriptions were identified with representation from across Canada. Many of these physicians also have a background in clinical investigation, research methods, guideline development, and knowledge translation.

Target Population and Interventions

Intensive hemodialysis was defined as any hemodialysis schedule that included an increase in frequency and/or an increase in session duration compared to conventional hemodialysis (ie, 3 times per week, 3-5 hours per session). Short daily hemodialysis was defined as 5 or more dialysis sessions per week with fewer than 3 hours per session. Long hemodialysis was defined as greater than or equal to 5.5 hours per session, 3-4 times per week, and long-frequent hemodialysis was defined as greater

Recommendation 1

Recommendation 1 is provided in Box 3.

Acknowledgements

Support: A grant was provided by the CSN to support this guideline development, and this work was funded in part by a Canadian Institutes of Health Research Meeting Planning and Dissemination Grant FRN # 106165.

Financial Disclosure: The authors declare that they have no relevant financial interests.

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    Originally published online April 15, 2013.

    G.E.N., R.A.M., and D.L.Z. contributed equally to this work.

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