Flexibility as an implementation strategy for a daily dialysis program

Background: Daily hemodialysis (DHD) is an interesting dialysis option, experienced worldwide by only a few hundred patients, because of clinical and logistic limitations. This study describes the main clinical and implementation results of a flexible policy applied in starting a DHD program. Methods: The setting is the University Nephrology Center of Turin, Italy (approximately 150 hemodialysis and 50 peritoneal dialysis (PD) patients) where in November 1998 a short daily DHD program was started. Outcome measures were logistical (enrolment rate, indications and drop-outs) and clinical (dialysis efficiency, metabolic control, hypertension and anemia control). Results: 25 patients experienced DHD, 16 (11% of the hemodialysis pool) were on DHD in November 2001; overall the DHD follow-up was 409.1 months (median 18, range 0.7-36 months). Flexibility was applied to schedules (patients modulated dialysis time and could switch to 3-4 sessions/wk); treatment setting (home: 11 patients, limited care center: 13; alternate settings: one); clinical selection (23/25 patients with comorbidity). Main reasons for choice were poor tolerance of previous schedule and the search for "best" treatment. Five patients dropped out (work reasons), one died on DHD and three were grafted. As compared to baseline, dialysis efficiency increased (EKRc pre-DHD 14.5 ± 2.1 mL/min; 17.4 ± 2.8 mL/min and 17.7 ± 3.5 mL/min at 1-6 months; p<0.000). Despite the potentially confusing effect of comorbidity, the main clinical data improved. Conclusion: A flexible approach allowed development of DHD in approximately 11 % of hemodialysis patients, with promising clinical results, despite frequent comorbidity.