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Alternative renal replacement therapies in end-stage renal disease

Andreas Pierratos, MD, FRCPC
Gihad E Nesrallah, MD, MSc, FRCPC, FACP
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


Despite improvements in technology and general medical care, the mortality rate of patients on maintenance dialysis remains alarmingly high, at approximately 15 to 20 percent per year [1,2]. In an attempt to improve outcomes, it was postulated that a higher dialysis dose than commonly provided during conventional dialysis may increase survival among patients undergoing renal replacement therapies [3].

However, this hypothesis was refuted in two large, well-designed studies in both hemodialysis and peritoneal dialysis patients:

The Hemodialysis (HEMO) Study found no improvement in patient survival when per-session hemodialysis dose was increased above the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations [4]. (See "Prescribing and assessing adequate hemodialysis".)

In the Adequacy of Peritoneal Dialysis in Mexico (ADEMEX) study, no reduction in mortality was seen with peritoneal dialysis doses greater than a weekly Kt/V of 1.7 [5]. (See "Prescribing and assessing adequate peritoneal dialysis".)

In the wake of these negative trials, more attention has turned to alternative dialysis schedules, including long intermittent hemodialysis, short daily hemodialysis, and nocturnal hemodialysis. Each of these approaches is discussed in detail separately. (See "Technical aspects of nocturnal hemodialysis" and "Short daily hemodialysis".)


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