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The mortality associated with hemodialysis (HD) remains high. Recent studies have found that a session time of 4 to 4.5 hours and an ultrafiltration rate of less than 10 cc/h/kg were each independently associated with a decreased mortality among HD patients. We started a thrice-weekly nocturnal HD program in May 2005 and have since enrolled a total of 16 patients. The Kt/V urea (2.6 +/- 0.65 vs. 1.2 +/- 0.16, mean +/- SD, P < .05) and serum phosphorus (4.4 +/- 1.1 v 5.3 +/-1.3 mg/dL, P =.049) values obtained 6 months after enrollment in the nocturnal HD program were significantly better than the baseline values obtained before the initiation of the nocturnal HD program. The ultrafiltration rate was 5.9 +/- 1.7 mL/h/kg 6 months after patients participated in the nocturnal HD program, whereas the rates for these same patients at baseline was 10.3 +/- 4.5 mL/h/kg. Psychosocial assessments were performed at baseline and again at 6 months. No difference was seen in the results of these assessments. We conclude that patients receiving long, in-center thrice-weekly nocturnal HD have a decrease in serum phosphate, an improvement in urea clearance, and a reduction in ultrafiltration rate to less than 10 mL/h/kg. This therapy appears to have no negative impacts on a variety of quality of life measures.

Frequent hemodialysis is currently conducted in a limited number of pediatric dialysis centers. However, the preliminary experience with children who have undergone procedures such as "daily" intensive hemodiafiltration and nocturnal hemodialysis has been positive, with the allowance for unrestricted diets and fluid intake, the lack of need for phosphate binders, excellent metabolic and blood pressure control, and, in the case of hemodiafiltration, excellent growth. The provision of frequent daily hemodialysis with the NxStage System has also recently been introduced to pediatrics. An overview about what is currently understood regarding the technical and clinical application of these approaches to therapy for children with end-stage renal disease form the basis for this article and highlight the impact of the procedures to date and the need for additional experience and collaborative data collection.

Background: Patients with end-stage renal disease (ESRD) have a high prevalence of sleep disorders, which are not improved by conventional hemodialysis (CHD). Although sleep disorders are commonly associated with complaints of excessive daytime sleepiness, the severity and pathogenesis of daytime sleepiness has not been evaluated objectively in patients with ESRD. Nocturnal hemodialysis (NHD) is a new technique that provides better clearance of uremic toxins than CHD and, consequently, may improve sleep quality and daytime sleepiness. The authors wished to determine the severity and pathogenesis of daytime sleepiness in patients with ESRD and evaluate the impact of NHD., Methods: Sleep quality was monitored by overnight polysomnography, and daytime sleepiness was assessed by the multiple sleep latency test (MSLT). These measurements were performed in 24 patients (15 men and 9 women, 44 +/- 10 years) while on treatment with CHD and were repeated in 15 patients after conversion to NHD., Results: The majority (54%) of patients on CHD were pathologically sleepy (somnolent group, mean sleep latency <5 minutes), and, in comparison with the remaining patients (alert group, mean sleep latency >5 minutes), their blood urea nitrogen (BUN; 77.9 +/- 9.8 v 60.2 +/- 12.0 mg/dL, P < 0.001; 27.8 +/- 3.5 v 21.5 +/- 4.3 mmol/L; P < 0.001), and periodic limb movement (PLM) index (57 +/- 47 v 6 +/- 10/hr; P = 0.002) were significantly higher. Furthermore, sleep latency was correlated with BUN (R = 0.58, P = 0.008). After conversion to NHD, there was a significant fall in BUN and the severity of sleep apnea, but the overall frequency of PLM and sleep fragmentation remained elevated. Nevertheless, there was a trend for the Somnolent group to become less sleepy on NHD, and this was associated with a modest reduction in the frequency of PLM., Conclusion: Excessive daytime sleepiness occurs in approximately 50% of patients with ESRD. The etiology appears to be related both to uremia and sleep fragmentation associated with PLM., (Copyright 2003 by the National Kidney Foundation, Inc.)

A 42-year-old man with end-stage renal disease (ESRD) was referred for conversion to nocturnal hemodialysis (NHD) therapy from conventional hemodialysis (CHD) therapy because of refractory intermittent claudication secondary to peripheral arterial disease (PAD). The patient was initiated on CHD therapy in 1976 and subsequently had undergone two unsuccessful renal transplantations. While on CHD therapy, his clinical course was complicated by worsening vascular and soft-tissue calcification. Extensive dystrophic soft-tissue calcification was noted bilaterally in his hands, lower extremities, and sacral region, requiring surgical excision. Lower-extremity arterial Doppler scans documented vascular calcification and a pronounced decrease in peripheral arterial flow bilaterally. After conversion to NHD therapy (7.5 h/session five times weekly), the patient became symptom free and had significant clinical improvements in (1) hemodynamics, measured by clinic blood pressure and two-dimensional echocardiography, (2) biochemical profile, and (3) a sustained improvement in arterial Doppler flow measured by duplex Doppler ultrasound. We conclude that NHD was able to improve lower-extremity PAD in our patient. Further observational and interventional studies are required to investigate the therapeutic potential of NHD for the treatment of PAD in patients with ESRD., (Copyright 2003 by the National Kidney Foundation, Inc.)

A program of respiratory muscle sparing in 9 patients with late stage Duchenne muscular dystrophy is presented. Results indicate that regular efficient night-time support by body respirator provides a constant significant improvement in daytime gas exchange for periods averaging up to 2 years following the occurrence of moderately severe respiratory failure. Until now, the longest survival is more than 4 years at the age of 28. the average PaCO2 and PaO2 before night ventilation were 60.8mmHg and 59.3mmHg, respectively. The levels after the program was begun were 45.5 (PaCO2) and 74.6 (PaO2). These arterial blood gas levels are acceptable for good cardiopulmonary homeostasis. There have been no deaths or episodes of cardiac failure since the program began. The ease of integrating the program into the patient's lifestyle and home are important advantages. Cost of equipment is discussed. The view that these patients are terminal must be qualified. A case is also made for early aggressive conservative measures including body respirators, postural drainage, chest physiotherapy with abdominal assisted coughing, intratracheal suctioning and bronchoscopy to combat respiratory infection, and decreasing the need of tracheostomy and volume ventilators which can be so disabling to the chronic restrictive lung disease (CRLD) patient. Research and development into better design of body respirators is vitally needed. Acute care hospitals must prepare themselves for such patients who now attain more independent living and longer lifespan. For this reason there is a growing need for these facilities to acquire tank ventilators for handling such patients who may need hospitalization for acute medical complications.