Clinical effectiveness and quality of life of conventional haemodialysis versus short daily...

Nephrol Dial Transplant (2008) 23: 2634–2646doi: 10.1093/ndt/gfn010Advance Access publication 3 April 2008

Original Article

Clinical effectiveness and quality of life of conventional haemodialysisversus short daily haemodialysis: a systematic review∗

Jeannete Punal1, Leonor Varela Lema1, Domingo Sanhez-Guisande2 and Alberto Ruano-Ravina1,3,4

1Galician Department of Health, Galician Agency for Health Technology Assessment, Santiago de Compostela, 2NephrologyService, Clinic University Hospital of Santiago de Compostela, 3Department of Preventive Medicine and Public Health,University of Santiago de Compostela and 4CIBER de epidemiologıa y salud publica, CIBERESP, Spain

AbstractBackground. End-stage renal disease is a troublesomehealth problem worldwide. The most usual renal replace-ment therapy is conventional haemodialysis (CHD), per-formed three times a week, 3.5–4 h per session. It has beenproposed that this schedule is unphysiologic and that dailyhaemodialysis would be a more appropriate schedule. Oneof the variants of daily haemodialysis is the so-called shortdaily haemodialysis (SDHD), performed five to seven timesper week, 1.5–3 h per session. The objective of this paperis to compare, through a systematic review, the clinical ef-fectiveness and safety of SDHD versus CHD.Methods. The following databases were searched: MED-LINE, EMBASE, NHS Centre for Reviews and Dissemina-tion (HTA, DARE and NHS EED), Cochrane, ISI Web ofKnowledge, IME and IBECS. Two independent reviewersdecided which papers were to be included after applyinginclusion and exclusion criteria. Any discrepancy was re-solved by consensus. The quality of the included papers wasmeasured using a quality scale developed for the purposeof this report.Results. Seventeen original articles were included. Therewere no randomized controlled trials. SDHD seems to bemore effective than conventional dialysis. Patients on dailyhaemodialysis seem to present less vascular access prob-lems, better control of hypertension and in turn a reduc-tion in the antihypertensive treatment, better quality of life,lower incidence of ventricular hypertrophy, lower consump-tion of rHuEPO due to the better control of anaemia and areduction in the use of phosphate binders as a consequenceof the better control of plasmatic phosphorous.Conclusions. SDHD might result in a better clinical ef-fectiveness, mainly through a better control of the arterial

Correspondence and offprint requests to: Alberto Ruano Ravina, GalicianDepartment of Health, Galician Agency for Health Technology Assess-ment, Edif Administrativo de San Lazaro, San Lazaro s/n, 15781 Santiagode Compostela, Spain. Tel: +34-981-541831; Fax: +34-981-542854;E-mail: [email protected], [email protected]∗The full systematic review (110 pages) can be downloaded in Spanish

completely free through the webpage of the Galician Agency for HealthTechnology Assessment (http://avalia-t.sergas.es/).

tension and, therefore, a lower consumption of antihyper-tensive drugs, and a better quality of life than CHD.

Keywords: end-stage renal disease; daily haemodialysis;MeSH terms: renal replacement therapy; renal dialysis;systematic review

Introduction

During the last decade, chronic kidney disease (CKD) de-pendent on renal replacement therapy (RRT) has increasedin all countries, and despite the technological advances,there have been no significant improvements in survival[1]. Currently, it is thought that an occult renal disease ex-ists in a relatively high percentage of the population, as hasbeen detected by the EPIRCE study in Spain [2]. This factcould also be present in other developed countries. At aworld level, the highest incidence rates of end-stage renaldisease (ESRD) are observed in the USA, Taiwan, Qatarand Japan. In the USA, 336 patients per million population(pmp) initiated RRT in 2003, whilst in European countries,in no case did this figure exceed 200 pmp. Survival of in-cident patients undergoing dialysis at 1, 2 and 5 years offollow-up is 85.7%, 75% and 49.4%, respectively [1].

In most countries, haemodialysis (HD) is the therapy ofchoice for patients with CKD [3]. Maintenance haemodial-ysis, using diffusion through hollow fibre cuprophan mem-branes can be dated back to the 1960s [4]. Since then,different HD modalities have emerged. A recent reviewhas updated the published evidence on their effectiveness[5,6]. There is also variability in the HD frequency. Whilethe conventional schedule is three times per week, it hasbeen suggested that a more physiological dialysis would bea daily schedule, with six times per week during 1.5–3 h,usually called short daily haemodialysis (SDHD). There areother HD frequencies, such as long nocturnal HD, whereHD is performed 8 h each night or the Tassin experience,three times per week and a duration of 8 h per session [7].

The objective of the present paper is to compare theclinical effectiveness and the quality of life of SDHD with

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Conventional versus daily haemodialysis 2635

Table 1. Selection criteria of the studies included in the review

Aspects considered Inclusion criteria

Type of schedule Patients treated on daily HD (five to seven times per week, 1.5–3 h/session)Comparison group, patients treated on CHD (three times per week, 3–5 h/session)

Type of publication Original papers and health technology assessment reportsStudy design Systematic reviews, meta-analysis, clinical trials, cohort studies and case control studiesSetting of the dialytic treatment All or at least half of the patients were dialyzed on daily HD in dialysis centres, hospitals or self-care unitsSample size A minimum of 10 patients were treated on daily HD. The comparison group had at least 10 patientsFollow-up period A minimum of 1 month, either on daily HD or on comparison groupPatient characteristics Patients with end-stage renal diseaseOutcome variables Blood pressure control, medication requirements, vascular accesses complications, hospitalizations and quality of

life. Inclusion of studies that assessed Kt/V, clearance of different molecules and other variablesStudy starting date The dialysis treatment was performed after January 1995 in all or part of patientsOther criteria Studies excluded those conducted on animals, patients treated with daily haemofiltration, or covering dialyzers or

dialysis membranes without including patients

HD: haemodialysis; CHD: conventional haemodialysis.

conventional haemodialysis (CHD) through a systematicreview of the literature.

Methods

Literature search

A systematic search of the literature was performed. Thedatabases used were MEDLINE (Pubmed), EMBASE (Sil-ver Platter), CRD (NHS Centre for Reviews and Dissem-ination), DARE (Database of Abstracts of Reviews of Ef-fectiveness), NHS EED (Economic Evaluation Database),Cochrane Library Plus, ISI Web of Knowledge (Institutefor Scientific Information, Philadelphia), as well as othernational databases. Search strategies were created for eachdatabase using different combinations and variations ofthe following core search strategies: (‘hemodialysis’ or‘haemodialysis’ or ‘dialysis’) and (‘daily’ or ‘quotidian’or ‘frequent’ or ‘home’). The search also included otherdatabases that provided information on ongoing clinicaltrials and research projects such as ClinicalTrials.gov,Centerwatch and HSRPROJ (Health Services ResearchProjects in Progress). A fully recursive search of referencelists of relevant papers was performed to find studies notidentified by the previous search. The search was restrictedto studies published in English, Spanish, French, Italian orPortuguese, between January 1995 and January 2007.

Paper selection

Papers identified in the search were reviewed separatelyby two of the authors and those considered potentially rel-evant were selected for further analysis. The full text ofthese papers was obtained and the two reviewers indepen-dently checked each trial for fulfilment of selection criteria(Table 1). The relevant data were rigorously extracted andrecorded in evidence tables that included information onstudy type, inclusion/exclusion criteria, patient character-istics (age, sex, comorbidities and time on dialysis) andfollow-up data.

The papers were classified depending on the type ofoutcome variables evaluated: vascular accesses complica-tions, cardiovascular outcomes, anaemia and EPO dosage,

nutritional status, therapy efficiency, morbidity and qualityof life.

Study quality assessment

Study quality was assessed using a specific scale adaptedfrom a previous study on haemodialysis [6,8]. The includedpapers were assessed in a blinded way by two independentreviewers. Differences >5% in the use of the scale werenot allowed and discrepancies were resolved by consen-sus after reviewing again carefully the study assessed. Theconcordance was measured using the intraclass correlationcoefficient which is equivalent to the kappa index for con-tinuous variables [9,10].

Results

Search results

The search strategy used identified 1.673 references. Ofthese, 69 studies were considered to be potentially rele-vant and were read at full text. After applying the inclu-sion/exclusion criteria, 17 articles were included in the sys-tematic review [11–27] (Figure 1). The majority of studieswere carried out in the USA and Italy. Only two studieswere published before the year 2000, one in 1996 [12] andthe other in 1999 [16]. The details of the included studiesmay be observed in Table 2.

Effectiveness of short daily haemodialysis

Vascular access problems. Seven articles [11,18,20–24]assessed the incidence of vascular access-related compli-cations. Of these, two [22,24] showed that patients receiv-ing daily dialysis had a lower incidence of vascular accessocclusions and a higher vascular access survival in relationto patients on conventional HD. Ting et al. [21] observedan average of 0.94 problems/year on DHD versus 1.01 onconventional HD, but this difference was not statisticallysignificant. Martins Castro et al. [18] showed an elevatedvascular accesses survival and a low number of failures onSDHD, not reporting outcomes on conventional HD. Theother three studies found similar incidences of vascular ac-cess failure with both HD frequencies [11,20,23].



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2636 J. Punal et al.

Fig. 1. Identification and selection of studies.

Cardiovascular outcomes: hypertension control and leftventricular hypertrophy. Six of the eleven trials that as-sessed the effect of short daily versus conventional dialysison blood pressure control observed greater reductions inboth systolic and diastolic aortic blood pressures for pa-tients on daily dialysis [11,12,16,19,22,24]. Williams et al.[23] observed a decrease in the systolic blood pressure dur-ing SDHD only. One paper [14] showed five hypertensivepatients during conventional HD that turned normotensiveon SDHD. In three studies, the decrease in blood pressureduring daily HD was not significant [15,21,26].

In 13 papers a comparison was made of medica-tion requirements during daily and conventional dialysis.Several studies found that when patients were transferredfrom conventional to short daily dialysis they could dis-continue or reduce the doses of antihypertensive drugs[12,14,19,21,23,24] or required a lower association of dif-ferent antihypertensive drugs [21,22]. The results of thesestudies are summarized in Table 3.

Five studies observed a significant reduction in cardiachypertrophy parameters when patients were changed fromconventional to daily HD [12,14,16,24,26]. Other inves-tigations found similar values for both dialysis regimens

[11,15]. In a study carried out by Odar-Cederlof et al. [17],elevated predialysis levels of B-type natriuretic peptide de-creased when patients were transferred to daily dialysis.Floridi et al. [13] showed that an SDHD regimen couldlower the mean levels of glycation-related substances ob-served in CHD.

Anaemia and EPO dosage. The majority of trials ob-served that erythropoietin doses could be reduced duringthe SDHD period [14,15,19,21,24,26] even though somestudies reported no significant changes [11,22]. In the studycarried out by Ting et al. [21] EPO requirements were re-duced in 45% after 12 months of follow-up. Traeger et al.[24] also observed a significant reduction after 1 year butEPO requirements increased slightly with longer follow-up periods (up to 6 years). During the daily HD period,the EPO treatment could be discontinued in some patients[14,19]. For example, Koshikawa et al. [19] found that in14 patients treated with SDHD, EPO was retired in 2 anddoses reduced in 5 patients.

Nutritional status. Ten studies reported the effects thatdaily dialysis had on various nutritional parameters.



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Tab

le2.

Stu

dies

com

pari

ngda

ilyha

emod

ialy

sis

(HD

)ve

rsus

conv

enti

onal

dial

ysis

(CD

)in

clud

edin

the

syst

emat

icre

view

Aut

hor/

year

Des

ign/

sam

ple

size

Pati

ents

char

acte

rist

ics

Pre

viou

sti

me

onH

DIn

clus

ion

crit

eria

Exc

lusi

oncr

iter

iaFo

llow

-up

peri

odon

daily

HD

Qua

lity

ofev

iden

ce(U

nite

dS

tate

sP

reve

ntiv

eS

ervi

ces

Task

Forc

e)

Spe

cifi

cqu

alit

ysc

alea

Fagu

glie

tal.

(200

6)[1

5]P

rosp

ectiv

eco

hort

stud

y;24

pati

ents

(12

onco

nven

tion

alH

Dan

d12

onda

ilyH

D)

Age

(mea

n):5

8.5

±16

.2ye

ars

Com

orbi

diti

es:n

otre

port

ed3

mon

ths

Pre

senc

eof

hype

rten

sion

Age

>15

and

<80

year

sC

lini

cala

ndbi

oche

mic

alst

able

cond

itio

nsat

leas

tin

the

prev

ious

mon

ths

spK

t/V

>1.

2

Lim

bam

puta

tion

Sev

ere

mal

nutr

itio

n

6m

onth

sII

-167

%

Mal

igna

ncie

s

Mar

tins

Cas

tro

etal

.(20

06)

[18]

Pre

–pos

ttri

al;2

6pa

tien

tsA

ge(m

ean)

:35.

6±

14.7

year

s(1

6–64

year

s)25

.1±

31.9

mon

ths

(1–1

59m

onth

s)In

form

edco

nsen

tM

edic

alco

ndit

ions

orpa

tien

tde

cisi

on

33.6

±18

.5m

onth

s(<

36m

onth

sin

grou

p1

and

>36

mon

ths

ingr

oup

2)

II-1

65%

Gol

dfar

b-R

umya

ntze

vet

al.(

2006

)[2

2]

Cro

ss-o

ver

clin

ical

tria

l;12

pati

ents

Age

:24–

75ye

ars

Com

orbi

diti

es:h

yper

tens

ion

(100

%),

diab

etes

(100

%),

diab

etes

mel

litu

s(8

.3%

),m

igra

ine

(8.3

%)

and

coro

nary

arte

rydi

seas

e(2

5%)

4w

eeks

Hyp

erte

nsio

n,in

trad

ialy

tic

hypo

tens

ion,

mus

cle

cram

ps,a

naem

iatr

eate

dw

ith

high

dose

sof

EP

O,l

arge

inte

rdia

lyti

cfl

uid

gain

,hyp

erka

laem

iaor

hype

rpho

spha

taem

ia

Med

ical

lyun

stab

leP

regn

antw

omen

Chi

ldre

n

8w

eeks

II-1

45%

Men

tally

disa

bled

Nes

rall

ahet

al.(

2006

)[2

5]

Pre

–pos

ttri

al;3

9pa

tien

ts(2

7on

hom

eH

Dan

d12

in-c

entr

eH

D)

Age

(mea

n):5

2.8

±15

.1ye

ars

(hom

eH

D)

and

59.2

±14

.6ye

ars

(in-

cent

reH

D)

Com

orbi

diti

es:h

yper

tens

ion

(77%

),di

abet

esm

elli

tus

(15%

)an

dhy

perp

arat

hyro

idis

m(2

7%)

6.4

–9.

9ye

ars

Not

repo

rted

Not

repo

rted

2.4

–4.

5ye

ars

II-1

45%

Com

orbi

diti

es:d

iabe

tes

mel

litu

s(2

4%on

hom

eH

Dan

d47

%in

-cen

tre

HD

),co

nges

tive

hear

tfai

lure

(29%

onho

me

HD

and

35%

in-c

entr

eH

D)

and

coro

nary

arte

rydi

seas

e(2

4%on

hom

eH

Dan

d12

%in

-cen

tre)

Ayu

set

al.

(200

5)[2

6]N

on-r

ando

miz

edcl

inic

altr

ial;

77pa

tien

ts(2

6on

daily

HD

and

51on

conv

enti

onal

HD

)

Age

(mea

n):5

1±

11.7

year

son

daily

HD

and

54±

8.5

year

son

conv

enti

onal

HD

Com

orbi

diti

es:n

otre

port

ed

3.87

±2.

97ye

ars

onco

nven

tion

alH

Dan

d2.

81±

2.98

onda

ilyH

D

Info

rmed

cons

ent

Not

repo

rted

12m

onth

sII

-171

%



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Tab

le2.

(Con

tinu

ed.)

Aut

hor/

year

Des

ign/

sam

ple

size

Pati

ents

char

acte

rist

ics

Pre

viou

sti

me

onH

DIn

clus

ion

crit

eria

Exc

lusi

oncr

iter

iaFo

llow

-up

peri

odon

daily

HD

Qua

lity

ofev

iden

ce(U

nite

dS

tate

sP

reve

ntiv

eS

ervi

ces

Task

Forc

e)

Spe

cifi

cqu

alit

ysc

alea

Yue

net

al.

(200

5)[2

7]P

re–p

ostt

rial

;21

pati

ents

Age

(mea

n):5

2±

3ye

ars

Com

orbi

diti

es:n

otre

port

ed12

mon

ths

Into

lera

nce

ofco

nven

tion

alH

D(r

efra

ctor

yin

trad

ialy

tic

hypo

tens

ion,

inte

rdia

lyti

cvo

lum

eov

erlo

ador

hype

rpho

spha

taem

ia)

Into

lera

nce

toda

ilyH

Dre

gim

en12

mon

ths

II-1

53.5

%

Am

inim

umof

6m

onth

son

conv

enti

onal

HD

Rey

nold

set

al.

(200

4)[1

1]P

re–p

ostt

rial

;39

pati

ents

(27

onho

me

HD

and

12in

-cen

tre

HD

)

Age

(mea

n):5

6±

8.6

year

s(3

6–66

year

s)C

omor

bidi

ties

:dia

bete

sm

elli

tus

(82%

),hy

pert

ensi

on(8

2%),

coro

nary

arte

rydi

seas

e(6

4%)

Mea

n:42

mon

ths

(6–2

34m

onth

s)Pa

tien

tstr

eate

dpr

evio

usly

onco

nven

tion

alH

DN

otre

port

ed2–

18m

onth

sII

-138

.5%

Wil

liam

set

al.

(200

4)[2

3]P

re–p

ostt

rial

;21

pati

ents

Age

(mea

n):5

7±13

year

s(3

5–84

year

s)C

omor

bidi

ties

:hyp

erte

nsio

n(5

7%),

diab

etes

mel

litu

s(1

4%),

left

vent

ricu

lar

hype

rtro

phy

(24%

)an

dch

roni

cob

stru

ctiv

epu

lmon

ary

dise

ase

(24%

)

75±

51m

onth

s(9

–184

mon

ths)

Pati

ents

who

had

been

stab

leon

thre

eti

mes

wee

kly

haem

odia

lysi

sth

erap

yfo

rat

leas

t3m

onth

s

Bac

tera

emia

,ps

ycho

sis,

seni

lity

His

tory

ofm

alig

nanc

yw

ithi

nth

epr

evio

us3

year

sH

isto

ryof

nonc

ompl

ianc

e

4w

eeks

II-1

42.5

%

Tra

eger

etal

.(2

004)

[24]

;G

alla

ndet

al.

(200

4)[2

8]

Pre

–pos

ttri

al;1

7pa

tien

tsA

ge:2

1–75

year

sC

omor

bidi

ties

:not

repo

rted

1–29

year

sPa

tien

tsw

ith

end-

stag

ere

nald

isea

setr

eate

dw

ith

conv

enti

onal

HD

Not

repo

rted

1–6

year

sII

-142

%

Med

ical

cond

itio

n:un

cont

roll

edbl

ood

pres

sure

left

vent

ricu

lar

hype

rtro

phy,

inab

ilit

yto

tole

rate

the

inte

rdia

lyti

cin

terv

al,m

alnu

trit

ion

Pre

scri

bed

dial

ysis

tim

eD

esir

eto

impr

ove

the

pati

ents

’sc

hedu

lefo

rw

ork

and

fam

ilyti

me

Pic

coli

etal

.(2

004)

[20]

Pro

spec

tive

coho

rtst

udy;

28on

daily

HD

(14

inho

me

HD

)an

d49

onco

nven

tion

alH

D(2

8in

hom

eH

D)

Age

:20–

77ye

ars

Com

orbi

diti

es:n

otre

port

ed65

5m

onth

sin

hom

eH

D;8

97m

onth

sin

in-c

entr

eH

D

Pati

ents

trea

ted

wit

hH

DN

otre

port

ed40

0m

onth

sin

hom

eH

Dan

d20

8m

onth

sin

-cen

tre

HD

II-2

58.5

%



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Tab

le2.

(Con

tinu

ed.)

Aut

hor/

year

Des

ign/

sam

ple

size

Pati

entc

hara

cter

isti

csP

revi

ous

tim

eon

HD

Incl

usio

ncr

iter

iaE

xclu

sion

crit

eria

Foll

ow-u

ppe

riod

onda

ilyH

D

Qua

lity

ofev

iden

ce(U

nite

dS

tate

sP

reve

ntiv

eS

ervi

ces

Task

Forc

e)

Spe

cifi

cqu

alit

ysc

alea

Tin

get

al.

(200

3)[2

1]P

re–p

ostt

rial

;42

pati

ents

Age

(mea

n):5

9.9

±16

.7ye

ars

Com

orbi

diti

es:h

yper

tens

ion

(90.

5%),

peri

pher

alva

scul

ardi

seas

e(4

0.5%

),is

chae

mic

hear

tdi

seas

e(3

5.7%

)an

ddi

abet

esm

elli

tus

(30.

9%)

12m

onth

sA

geol

der

than

18ye

ars

Thr

eeor

four

tim

esw

eekl

yha

emod

ialy

sis

orpe

rito

neal

dial

ysis

for

atle

ast3

mon

ths

Ade

quat

eva

scul

arac

cess

Abi

lity

toun

ders

tand

and

sign

info

rmed

cons

ent

Wil

ling

ness

tore

use

dial

yzer

sM

edic

alin

dica

tion

s:in

abil

ity

toto

lera

tein

terd

ialy

tic

inte

rval

,ina

bili

tyto

adeq

uate

lyco

ntro

lhyp

erte

nsio

n,m

alnu

trit

ion,

amyl

oido

sis

Non

med

ical

indi

cati

ons:

desi

reto

impr

ove

gene

ralw

ell-

bein

gor

soci

alac

tivit

ies

Not

repo

rted

72m

onth

sII

-150

%

Kos

hika

wa

etal

.(20

03)

[19]

Cro

ss-o

ver

clin

ical

tria

l;23

pati

ents

Age

(mea

n):5

5.8

±9.

6ye

ars

Com

orbi

diti

es:n

otre

port

ed11

.1±

6.6

year

sPa

tien

tsw

ith

end-

stag

ere

nald

isea

seun

derg

oing

haem

odia

lysi

sth

ree

tim

espe

rw

eek

Not

repo

rted

12w

eeks

II-1

43%

Flo

ridi

etal

.(2

002)

[13]

Pre

–pos

ttri

al;

32pa

tien

tsA

ge(m

ean)

:N

on-d

iabe

tic:

57.8

±19

.3ye

ars

(fem

ales

)an

d56

.3±

15.3

year

s(m

ales

)D

iabe

tic:

52.5

±17

.0ye

ars

(fem

ale)

and

54.8

±22

.9ye

ars

(mal

e)C

omor

bidi

ties

:dia

bete

sm

elli

tus

(34%

)

881

±35

8da

ysN

otre

port

edA

ge>

80or

<25

year

sS

ever

em

alnu

trit

ion

Mal

igna

ncie

s

6m

onth

sII

-159

.5%

Gal

land

etal

.(2

001)

[14]

Pre

–pos

ttri

al;

10pa

tien

tsA

ge(m

ean)

:44.

9±

13.8

year

s(2

1–66

year

s)C

omor

bidi

ties

:not

repo

rted

10.1

±6.

7ye

ars

(1–1

9ye

ars)

Not

repo

rted

Not

repo

rted

23.2

±12

.7m

onth

s(1

3–78

mon

ths)

II-1

34.5

%

Pin

ciar

olie

tal.

(199

9)[1

6]P

re–p

ostt

rial

;22

pati

ents

(11

inho

me

HD

and

11in

-cen

tre

HD

)

Age

(mea

n):5

0ye

ars

(27–

73ye

ars)

Com

orbi

diti

es:h

yper

tens

ion

(54%

)an

ddi

abet

esm

elli

tus

(14%

)

1–19

2m

onth

sFo

rm

edic

alin

dica

tion

sFo

rli

fest

yle

reas

ons

Not

repo

rted

Mea

n:56

.2m

onth

s(1

2–12

7m

onth

s)

II-2

40.5

%

Buo

ncri

stia

niet

al.(

1996

)[1

2]

Pre

–pos

ttri

al;

34pa

tien

tsA

ge(m

ean)

:55.

8±

10.6

year

s(h

yper

tens

ive)

and

57.8

±10

.6ye

ars

(nor

mot

ensi

ve)

12m

onth

sPa

tien

tsun

derg

oing

conv

enti

onal

HD

prev

ious

lyN

otre

port

ed24

mon

ths

II-2

34.5

%

Com

orbi

diti

es:n

otre

port

edO

dar-

Ced

erlo

fet

al.(

2006

)[1

7]

Pre

–pos

ttri

al;

12pa

tien

tsA

ge(m

ean)

:55

±4

year

s(3

5–84

year

s)C

omor

bidi

ties

:lef

tven

tric

ular

hype

rtro

phy

(3pa

tien

ts),

hype

rten

sion

(3),

diab

etes

mel

litu

s(2

),ch

roni

che

artf

ailu

re(1

)an

dis

chae

mic

hear

tdis

ease

(2)

9–18

4m

onth

sIn

form

edco

nsen

tN

otre

port

ed4

wee

ksII

-138

.5%

a Not

e:th

equ

alit

yof

the

incl

uded

pape

rsw

asas

sess

edby

two

inde

pend

entr

evie

wer

s.H

D:h

aem

odia

lysi

s.



ownloaded from


2640 J. Punal et al.T

able

3.B

lood

pres

sure

and

anti

hype

rten

sive

drug

requ

irem

ents

repo

rted

inth

ein

clud

edst

udie

s

Aut

hor/

year

Foll

ow-u

ppe

riod

/sam

ple

size

(n)

Mai

nou

tcom

esR

emar

ks

Blo

odpr

essu

reA

ntih

yper

tens

ive

requ

irem

ents

Wil

liam

set

al.(

2004

)[2

3]1

mon

th/n

:21

pati

ents

Mac

hine

alar

ms

wer

e30

%le

ssfr

eque

ntdu

ring

daily

dial

ysis

than

conv

enti

onal

dial

ysis

.Mea

npr

edia

lysi

ssy

stol

icbl

ood

pres

sure

onD

HD

was

132

mm

Hg

vers

us14

0m

mH

gon

conv

enti

onal

HD

.Thi

sbl

ood

pres

sure

decr

ease

dth

roug

hout

the

foll

ow-u

ppe

riod

.The

rew

ere

nosi

gnif

ican

tdi

ffer

ence

sin

dias

toli

cbl

ood

pres

sure

Two

pati

ents

disc

onti

nued

thei

ran

tihi

yper

tens

ive

med

icat

ions

duri

ngth

eD

HD

peri

od,b

utth

ere

wer

eno

diff

eren

ces

inth

em

ean

num

ber

ofbl

ood

pres

sure

pill

sad

min

istr

ated

onD

HD

(1.9

)co

mpa

red

wit

hco

nven

tion

alH

D(1

.7)

Kos

hika

wa

etal

.(20

03)

[19]

12w

eeks

/n:2

3pa

tien

tsT

hem

ean

syst

olic

bloo

dpr

essu

reat

base

line

was

152.

3m

mH

gan

dat

the

end

offo

llow

-up

was

136.

6m

mH

g.T

hem

ean

dias

toli

cbl

ood

pres

sure

decr

ease

dfr

om84

.3du

ring

the

conv

enti

onal

HD

peri

odto

77.2

mm

Hg

duri

ngth

eD

HD

peri

od

Of

11pa

tien

tsw

how

ere

trea

ted

wit

han

tihy

pert

ensi

vedr

ugs,

5w

ithd

rew

from

the

drug

san

din

1th

edo

sew

asre

duce

d

Tra

eger

etal

.(20

04)

[24]

1ye

ar/n

:17

pati

ents

The

mea

nbl

ood

pres

sure

was

103

mm

Hg

atba

seli

nean

d91

mm

Hg

at1-

year

foll

ow-u

pon

DH

DO

fni

nepa

tien

tstr

eate

dw

ith

anti

hype

rten

sive

drug

s,th

ism

edic

atio

nw

asst

oppe

din

seve

nan

dth

edo

sere

duce

din

two

pati

ents

Buo

ncri

stia

niet

al.(

1996

)[1

2]1

year

/n:3

4pa

tien

tsA

tbas

elin

e,th

em

ean

syst

olic

bloo

dpr

essu

rew

as10

6m

mH

gan

d95

.5m

mH

gaf

ter

1ye

arof

DH

D.

Inth

ehy

pert

ensi

vegr

oup

the

bloo

dpr

essu

rede

crea

sed

from

120

to10

3.4

mm

Hg

13pa

tien

tsst

oppe

dan

tihy

pert

ensi

vetr

eatm

enta

ndth

eot

hers

requ

ired

alo

wer

asso

ciat

ion

ofdi

ffer

enta

ntih

yper

tens

ive

drug

s

20pa

tien

tsw

ere

hype

rten

sive

and

14w

ere

norm

oten

sive

Ayu

set

al.(

2005

)[2

6]12

mon

ths/

n:77

pati

ents

The

rew

ere

nosi

gnif

ican

tdif

fere

nces

inbl

ood

pres

sure

at12

mon

ths

offo

llow

-up

com

pare

dw

ith

base

line

valu

es

Non

-ran

dom

ized

clin

ical

tria

lw

ith

conc

urre

ntco

ntro

ls

Gal

land

etal

.(20

01)

[14]

Mea

nfo

llow

-up:

23m

onth

s/n:

10pa

tien

tsFi

vepa

tien

tsw

ere

hype

rten

sive

duri

ngco

nven

tion

alH

Dan

dth

eyw

ere

norm

oten

sive

duri

ngth

eD

HD

regi

men

The

sepa

tien

tsst

oppe

dan

tihy

pert

ensi

vetr

eatm

ent

Tin

get

al.(

2003

)[2

1]1

year

/n:2

0pa

tien

tsT

hesy

stol

icbl

ood

pres

sure

was

eith

erst

able

orsi

gnif

ican

tlyim

prov

edon

DH

D.D

iast

olic

bloo

dpr

essu

rew

asno

rmal

onco

nven

tion

alH

D(7

9±

14m

mH

g)an

ddi

dno

tcha

nge

sign

ific

antly

onD

HD

The

num

ber

ofdi

ffer

enta

ntih

yper

tens

ive

med

icat

ions

per

pati

entd

ecre

ased

69%

from

1.3

to0.

4.T

henu

mbe

rof

anti

hype

rten

sive

pill

spe

rpa

tien

tdec

reas

ed60

%(f

rom

12.6

to5.

3pi

lls/

wee

k)R

eyno

lds

etal

.(20

04)

[11]

1ye

ar/n

:11

pati

ents

.T

hebl

ood

pres

sure

decr

ease

dto

13m

mH

gan

ddi

asto

lic

bloo

dpr

essu

reto

6m

mH

gat

the

end

offo

llow

-up

com

pare

dat

base

line

valu

es

The

mea

nan

tihy

pert

ensi

vere

quir

emen

tsde

crea

sed

from

2to

1

Gol

dfar

b-R

umya

ntze

vet

al.

(200

6)[2

2]2

mon

ths/

n:12

pati

ents

The

syst

olic

bloo

dpr

essu

rede

crea

sed

by9

mm

Hg

and

dias

toli

cbl

ood

pres

sure

by6

mm

Hg.

The

valu

esre

turn

edto

the

base

line

valu

esaf

ter

pati

ents

resu

med

conv

enti

onal

HD

The

rew

ere

nost

atis

tica

llysi

gnif

ican

tdif

fere

nces

inco

nsum

ptio

nof

anti

hype

rten

sive

drug

sbe

twee

nbo

thdi

alys

ism

odal

itie

s

Aft

er2-

mon

thD

HD

peri

od,

pati

ents

retu

rned

toco

nven

tion

alH

D

Pin

ciar

olie

tal.

(199

9)[1

6]M

ean

foll

ow-u

p:56

.2m

onth

s(1

2–12

7)/n

:22

pati

ents

Bot

hsy

stol

icbl

ood

pres

sure

(174

mm

Hg

atba

seli

ne,1

41m

mH

gat

12m

onth

san

d14

1m

mH

gat

60.7

mon

ths)

and

dias

toli

cde

crea

sed

(94

mm

Hg

atba

seli

ne,8

2m

mH

gat

12m

onth

san

d80

.9m

mH

gat

60.7

mon

ths)

duri

ngD

HD

Sys

toli

can

ddi

asto

lic

bloo

dpr

essu

rew

asas

sess

edin

hype

rten

sive

pati

ents

Fagu

glie

tal.

(200

6)[1

5]6

mon

ths/

n:24

pati

ents

The

rew

ere

nosi

gnif

ican

tdif

fere

nces

inbl

ood

pres

sure

betw

een

conv

enti

onal

HD

vers

usD

HD

No

sign

ific

antd

iffe

renc

esob

serv

edin

the

num

ber

ofan

tihy

pert

ensi

vedr

ugs

adm

inis

trat

edPa

tien

tson

DH

Dco

mpa

red

wit

han

exte

nded

form

ofco

nven

tion

alH

D(4

.5–5

h/se

ssio

n)

DH

D:d

aily

haem

odia

lysi

s.



ownloaded from



Significant improvements were observed in the majorityof the nutritional parameters studied [protein intake, nor-malized protein nitrogen appearance rate (nPNA), calorieintake, fluid intake, mean dry weight, body mass index andlean body mass] when patients were transferred from CHDto SDHD [14,16,21–24,26]. Body weight gain increased insome studies [14,19,21] but decreased [24,26–28] or re-mained unchanged in others [16].

Therapy efficiency. With the exception of one study [27],all articles showed that the daily dialysis dose (Kt/V) wasincreased in the short dialysis period [11,19–21,23,24,28].Williams et al. [23] found that with daily dialysis, phos-phorous removal per week increased by 10%. Five out ofseven studies that provided results on serum phosphate lev-els found that these were reduced during SDHD [23–26,28].Reynolds et al. [11] found no significant change for thisparameter. Another trial [27] observed that the predialysisserum phosphate concentrations decreased until 6 monthsof follow-up on SDHD and remained similar at 12 monthsof follow-up compared to 6 months.

Whilst some studies showed a reduction in phos-phate binder usage when patients were switched to dailyhaemodialysis [14,26,28], others found no significant mod-ifications [11,21,27]. Only one [24] of the three [11,22,24]studies that assessed β2-microglobulin levels during SDHDfound statistical significant differences between CHD(30.5 ± 11 mg/dl) and SDHD (24.6 ± 7.8 mg/dl).

Morbidity. The results of three studies that compared hos-pitalization rates and length of stays during the SDHD andCHD period showed opposite results. Whilst one studyfound a decrease in the number of admissions and length ofhospital stays during the SDHD therapy [21] another studyfound an increase in these events [23]. In one investiga-tion no significant differences were found between the twodialysis modalities [11].

Quality of life. Quality of life assessments were carriedout using different questionnaires, such as Kidney DiseaseQuality of Life-Short Form (KDQOL-SF) [19,21,22],SF-36 [11,24] and Alberta Quality of Life Instrument[23]. Practically all of the studies observed that the overallassessment of quality of life improved when patients wereon SDHD therapy [11,14,19,21–24]. Significant improve-ments were reported in various symptoms (cramps, chills,hypertensive episodes, itchy skin and lack of appetite),energy status, burden of kidney disease, social interaction,physical functioning and mental health status [21–23].In general, patients reported that they were feeling betterduring the daily dialysis period [21–23]. The results onquality of life are shown in Table 4.

Assessment of the quality of the included studies

The average scores awarded by the two independent inves-tigators for all the studies included in the review are pre-sented in Figure 2. The average maximum score achievedwas 71% [26] and the average minimum score 34.5% [12].The overall quality was low since the mean and medianscores were <50% (48.94% and 45%, respectively). Con-

cordance between the two independent investigators washigh. The intraclass correlation coefficient was 0.96 (IC95%, 0.89–0.98), demonstrating a high level of agreementbetween the two reviewers.

Discussion

The results of this systematic review suggest that SDHDmight offer a better clinical effectiveness than CHD interms of hypertension control and medication requirements,including EPO treatment. There does not seem to be anydifferences in vascular access related complications. A bet-ter clearance of AGE peptides, urea and phosphate has alsobeen observed. All the studies included are consistent witha better quality of life for patients treated with SDHD versusconventional HD.

It has been previously suggested that the risk of vas-cular accesses failure and the incidence of complicationssuch as stenosis could be greater in SDHD due to the fre-quent needle punctures. Despite these claims previous stud-ies did not relate the frequency of punctures with vascularaccesses dysfunction [29,30]. Some studies have shown thatother risk factors such as advanced atherosclerosis, alteredhaemostasis and metabolic abnormalities (diabetes, hyper-lipidaemia etc.) could be predictors of fistula dysfunction[31–33]. The results of this review suggest that there areno significant differences in vascular problems betweenCHD and a short daily dialysis. Some investigations haveeven reported that fistulas have better outcomes with dailyhaemodialysis compared to chronic haemodialysis [34–36].Some of the reasons that may explain this finding would bea better blood pressure control [37], improved haemostasis[38] with decreased haematoma formation at the puncturelevel [39] or reduced homocysteine levels [40].

The improvement in blood pressure control and thereduction in antihypertensive treatment has been previ-ously explained by a reduction of extracellular fluid excess[35,41,42]; these outcomes were also observed in two in-cluded papers [15,22], a better control of dry weight thatwould help attain a lower interdialytic volume [11,14] anda better control of sodium balance [12,19]. With short dailydialysis the volume status is more stable over time than withCHD. In the studies reviewing these factors were clearlycorrelated with a reduction in antihypertensive medica-tions when patients achieved better blood pressure control[11,12,14,19,23,24]. When there were no blood pressureimprovements or these were very slight, changes in theseparameters did not lead to lower medication consumption[15,22].

Another finding in relation to medication consumptionwas the reduction in phosphate binder usage in patientswho received short daily dialysis. Since these treatmentsare indicated for the control of phosphorous levels, it isindicative that SDHD provides a higher clearance of theseproducts and reduces serum phosphorus levels. Hyperphos-phataemia can induce vascular calcification [43] and prob-ably contribute to left ventricular hypertrophy [44], thussuggesting an important mechanism for the possible bene-ficial effects of SDHD.



ownloaded from


2642 J. Punal et al.T

able

4.Q

uali

tyof

life

resu

lts

obse

rved

inth

ein

clud

edst

udie

s

Aut

hor/

year

Foll

owup

peri

od/n

umbe

rof

pati

ents

(n)

Qua

lity

ofli

fesc

ale

empl

oyed

Mai

nou

tcom

esR

emar

ks

Gol

dfar

b-R

umya

ntze

vet

al.

(200

6)[2

2]Fo

llow

-up

to4,

8,12

and

16w

eeks

(n=

12)

KD

QO

L-S

FE

ight

of12

pati

ents

(66%

)st

ated

that

they

felt

bett

ersu

bjec

tivel

yon

DH

D.S

igni

fica

ntim

prov

emen

tin

sym

ptom

s,bu

rden

ofki

dney

dise

ase,

soci

alin

tera

ctio

nan

dfu

ncti

onin

gan

den

ergy

leve

lon

DH

D.W

hen

pati

ents

retu

rned

toco

nven

tion

alH

Dth

equ

alit

yof

life

scor

esw

ere

low

er

The

scor

esw

ere

tran

sfor

med

into

a0-

to10

0-po

ints

cale

Rey

nold

set

al.(

2004

)[1

1]Fo

llow

-up

to1,

3,6

and

12m

onth

son

DH

D(n

=12

pati

ents

)

SF

-36,

Bec

kD

epre

ssio

nIn

vent

ory,

Pati

ent-

Rat

edA

nxie

tyS

cale

(PR

AS

)an

dPa

tien

tAss

esse

dQ

uali

tyof

Lif

e(P

AQ

OL

).T

heM

enta

lCom

pone

ntS

core

and

Phy

sica

lCom

pone

ntS

core

wer

eth

epr

imar

you

tcom

esof

SF

-36

Dep

ress

ion

impr

oved

sign

ific

antly

,mea

nB

DI

scor

esfe

llfr

om15

.4at

base

line

to7.

8at

12m

onth

s.T

hePA

QO

Lin

crea

sed

from

6.4

to7.

6at

1ye

ar.N

one

ofth

edi

ffer

ence

sfo

rot

her

ques

tion

nair

esc

ores

wer

est

atis

tica

llysi

gnif

ican

t

Rep

orte

dnu

mer

ical

valu

esof

each

scal

e

All

pati

ents

repo

rted

impr

oved

soci

aliz

atio

n/re

lati

onsh

ips

and

said

they

wou

ldco

ntin

ueD

HD

Tin

get

al.(

2003

)[2

1]Fo

llow

-up

to3

mon

ths

and

each

year

(n=

42pa

tien

ts)

KD

QO

Lve

rsio

n1.

3T

here

wer

ehi

ghly

sign

ific

anti

mpr

ovem

ents

wit

hin

3m

onth

sof

star

ting

DH

Dth

erap

yin

ener

gy/f

atig

ue,s

ympt

oms/

prob

lem

sli

st,

effe

cts

ofki

dney

dise

ase,

cogn

itiv

efu

ncti

on,

qual

ity

ofso

cial

inte

ract

ion

and

sym

ptom

sdu

ring

and

afte

rdi

alys

is.A

t12

mon

ths,

wer

eim

prov

emen

tsob

serv

edin

emot

iona

lw

ell-

bein

g,so

cial

func

tion

and

sexu

alfu

ncti

on.T

here

wer

eno

sign

ific

ant

diff

eren

ces

whe

n3-

mon

thsc

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Fig. 2. Mean quality score of the included papers.

The reduction of erythropoietin treatment observed inmany studies [14,15,19,21,22,24,26] could reflect not onlya better nutritional status but also the greatest removal ofuraemic toxins that may play a role in inhibition of ery-thropoiesis and therefore contribute to the improvementof anaemia and to the lowering of erythropoietin doses[34,45,46]. Nevertheless, some investigations have showna higher need for EPO drugs and this could be associatedwith higher blood losses [22] or increased phlebotomy orinflammation due to the more frequent dialysis sessions andconsequent exposure to the extracorporeal circuit that canenhance inflammation [11].

The results are not clear as to the improvements in hos-pital admissions rates or length of stays. Hospitalizationrates are directly associated with the number and severityof the comorbidities and also with the safety of the dial-ysis technique. Some studies suggest that SDHD causesless interdialytic fluid fluctuations and gives more freedomto the patients to elaborate their diet and this is likely tobring about a better appetite and hence a better nutritionalstatus [24,34,47–49] with the disappearance of anorexia[14], a condition very frequent in haemodialysed patients.The improvement in nutritional status, hormonal levels andother improvements associated with the greatest removalof substances related to uraemia should result in a bet-ter well-being, less complications and, as a consequence,fewer and shorter hospital admissions [16,50]. This effectwas not reflected in all of the studies analysed in this pa-per. Whilst the hospitalization days and rates decreased intwo studies [18,21], they increased [23] or remained un-

changed in other investigations [11]. This is noteworthy,since if it is expected for SDHD to have better clinicalresults this fact should be reflected in hospital admissions,which is not the case in the revised literature. SDHD seemsto contribute to a higher clearance of advanced glycationend-products (AGEs) [13]. AGE peptides derived from thecatabolism of glycated proteins accumulate in the plasmaof patients undergoing HD and may contribute to the onsetof some long-term complications such as atherosclerosis,amyloidosis and neurodigestive processes [51–55]. Reduc-tions in left ventricular hypertrophy parameters, possiblydue to better blood pressure control [12,24], decrease ininterdialytic weight gain [24,26] and decrease in predial-ysis plasma levels of natriuretic peptide [17], were otherfindings observed and these are of clinical interest becausethey are well-known risk factors for cardiovascular disease.The left ventricular hypertrophy cardiovascular disease isthe leading cause of death in patients with ESRD [56].

In comparison to CHD, short daily dialysis presenteda greater urea clearance (Kt/Vurea) [11,19–21,23,24,28]. Ithas been previously suggested that urea clearance can fluc-tuate during the dialysis session, with the dialyzer ureaclearance higher in the first hours of the session and lowerat the end [57]. The shorter duration of the dialysis sessionsin SDHD could explain the increased urea clearance.

There were no significant reductions observed in theremoval of β2-microglobulin and this could be due to thehigh molecular weight of this protein, 11 800 dalton [34,58].It has been shown that SDHD is more efficient than CHD inthe clearance of low and intermediate molecules but doesnot provide a higher removal of high weight molecules,such as β2-microglobulin [34].

Whilst the majority of studies show a greater clearanceof phosphorous in short daily dialysis [23–26,28], othersdo not find significant changes [11,27]. Buoncristiani et al.[59] have pointed out that SDHD sessions >2 h do not leadto an increased removal of uraemic substances, suggestingthat 2 h is the ideal scheme and differences in the sessionduration cannot explain the observed discrepancies. It hasbeen indicated that clearance of phosphorous can depend onthe predialysis levels of phosphorous, this clearance beinghigher when these levels are >5 mg/dl [60–63]. Ayus et al.[64] have suggested that SDHD is not very efficient whenserum phosphorous levels are between 4 and 4.5 mg/dl.

The studies reflected that the quality of life improvedwhen patients were transferred from conventional dialysisto SDHD [11,14,19,21–24]. Similar results have also beenobserved in the London Study (Ontario, Canada), wherepatients reported a better quality of life in both SDHDand nocturnal haemodialysis when compared with CHD[65,66]. The studies included in the present review reportedreductions in the incidence of symptoms such as nausea,vomiting, itchy skin, cramps, chills, hypertensive episodesand dizziness during daily dialysis treatment, which reflectsa better dialysis tolerance. Improvements were also reportedin physical and mental health status. Results were consis-tent even though different questionnaires and instrumentswere used to measure quality of life, some specific to renaldisease and others to general health survey questionnairessuch as SF-36. Although results suggest that quality of lifeis improved for SDHD versus CHD, it cannot be ruled out



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that this improvement could be simply due to the change toa new procedure, since in these cases there is frequently anincrease in the attention paid to a patient. Furthermore, re-searchers involved in studies assessing the effectiveness ofa new therapy tend to be enthusiastic about on its results andthere exists the possibility of transmitting this enthusiasmto the patients included, influencing the results. It is impor-tant to note that two studies that have not been included inthis review because they did not comply with the inclusion/exclusion criteria, have found that some patients were notwilling to change from a CHD to an SDHD schedule[67,68]. These two studies found that 44% [67] and 59% ofthe patients [68] were reticent to start short daily dialysis forvarious reasons, such as a greater dependence on a dialysismachine and a worsening in their quality of life regard-ing social relationships, and this aspect must be taken intoaccount when deciding to implement a SDHD schedule.

There are certain limitations in this systematic review.Since there is no MeSH term for haemodialysis nor forthe different dialysis modalities, it complicates the searchquery in the PubMed (Medline) database. We had to use asearch strategy with free text words to find the bibliographyso we cannot exclude having missed some articles, eventhough we feel this is highly improbable since we hand-searched references lists of all articles retrieved and foundno additional articles.

This systematic review did not consider all daily dialysistreatment schedules, but considered only those frequentlydefined as short daily dialysis schedules: five to seven timesper week sessions with lengths ranging from 1.5 to 3 h. Thefindings of this review cannot, therefore, be generalized toother daily schedules such as long nocturnal haemodialy-sis or schedules with much longer durations. Two studies[36,69] were excluded from the present analysis becausedaily dialysis was performed at home in the majority ofpatients (70% and 80% were treated at home, respectively).The decision to exclude these studies was taken after con-sulting with various nephrologists, since it was consideredthat these patients could present a better compliance withthe dialysis schedule, better haemodynamic profiles andless comorbidities.

The different prescribed dialysis doses among studies,and even within the same study, greatly limit the drawingup of conclusions. When comparing both haemodialysisfrequencies, the ideal situation would be one where thedialysis doses were the same for both. Nevertheless, insome of the assessed studies Ting et al. [21] and Ayuset al. [26], the weekly time on dialysis was longer in SDHDthan in CHD (13–18 h versus 12 h) while in others [12,27]the CHD weekly time was fixed at 12 h and the SDHD washighly variable (9–22 h/week). Four of the included papers[11,16,20,25] did not show the total duration of dialysissessions at least in one of the frequencies assessed. Thesedifferences in the Kt/V achieved could affect the overallresults, the clearance of phosphorus and also the patient’squality of life. Our report strongly supports the need forbetter quality studies to assess the effectiveness of SDHD.

Another important shortcoming is the low overall meanand medium quality scores achieved by the studies, whichwere <50%. Concordance between the two independentreviewers was high, indicating that the scale specifically

designed for this review was easy to use and can clearlydifferentiate low- from high-quality studies. The mostimportant shortcomings found were small sample size,short follow-up periods and restrictive inclusion/exclusioncriteria that do not allow for a generalization of the resultsto all of the dialyzed population.

It has to be kept in mind that in the present systematicreview there are some decisive aspects that are not discussedbecause they were not the objective of this work. Theseaspects would be related to daily haemodialysis such astransportation to the facility (entailing higher costs), higherperceived burden of disease and higher consumption ofconsumables. A higher dropout of patients in the SDHDarms of the included studies cannot, therefore, be dismissed,perhaps overestimating the positive results.

In conclusion, the literature analysis indicates that in gen-eral terms, clinical outcomes might be better with shortdaily dialysis than with CHD. The main findings wereimprovements in blood pressure control and medicationrequirements. There were no differences found regardingmorbidity or mortality and this is noteworthy since it isthe ultimate expected result of SDHD versus CHD. Theevidence supports the hypothesis that quality of life im-proves when patients are transferred from a conventional toa SDHD regimen although neither of the quality of life stud-ies surpassed 50 patients. The randomized clinical studiesthat are currently underway will provide good quality andvaluable information to determine the real effectiveness ofdaily dialysis in comparison to CHD.

Acknowledgements. The authors wish to thank Dr Maduell from theHospital Clinic of Barcelona for the critical review of an extended ver-sion of this manuscript. This study was funded by the Health ResearchFund (Fondo de Investigaciones Sanitarias–FIS) grant PI05/90003 fromthe Spanish Ministry of Health & Consumer Affairs as part of a re-search project entitled ‘Clinical effectiveness of two frequencies of chronichemodialysis: conventional versus short daily hemodialysis.’

Conflict of interest statement. None declared.

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Received for publication: 5.9.07Accepted in revised form: 7.1.08



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