Review
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. Mar 25, 2022; 11(2): 39-57
Published online Mar 25, 2022. doi: 10.5527/wjn.v11.i2.39
Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity
Bernard Canaud, Jeroen P Kooman, Nicholas M Selby, Maarten Taal, Andreas Maierhofer, Pascal Kopperschmidt, Susan Francis, Allan Collins, Peter Kotanko
Bernard Canaud, Allan Collins, Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
Bernard Canaud, Department of Nephrology, Montpellier University, Montpellier 34000, France
Jeroen P Kooman, Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
Nicholas M Selby, Maarten Taal, Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
Andreas Maierhofer, Pascal Kopperschmidt, Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
Susan Francis, Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
Peter Kotanko, Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
Author contributions: All authors contributed equally to concept, writing, and revising of the manuscript.
Conflict-of-interest statement: Canaud B is acting as scientist consultant for FMC. No conflict of interest exists for other authors.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Bernard Canaud, MD, PhD, Emeritus Professor, Global Medical Office, Fresenius Medical Care, 1 Else Kroner Str, DE-61352, Bad Homburg 61352, Germany. bernard.canaud@fmc-ag.com
Received: March 26, 2021
Peer-review started: March 26, 2021
First decision: October 17, 2021
Revised: October 30, 2021
Accepted: March 23, 2022
Article in press: March 23, 2022
Published online: March 25, 2022
Processing time: 363 Days and 19.6 Hours
Abstract

The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.

Keywords: End stage kidney disease; Cardiovascular mortality; Dialytic morbidity; Circulatory stress; Biologic storm; Dialysis sickness; Personalized medicine

Core Tip: In this in-depth review, we summarize the hidden effects of intermittent hemodialysis (HD) therapy, namely, dialysis sickness and dialysis related morbidity. We call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects. The final aim is to reduce cardiovascular burden and improve patient outcomes.