There has been renewed focus on providing hemodialysis more frequently than the conventional thrice-weekly treatments. The Frequent Hemodialysis Network Trials were landmark studies examining a variety of outcomes with more frequent dialysis versus conventional dialysis. Having to plan and take time out of their daily schedule to receive hemodialysis can impact the mental health of patients undergoing dialysis. Increasing the frequency of dialysis can further impact the mental health. A recent article in the American Journal of Kidney Diseases examined how frequent hemodialysis affects mental health. Corresponding author Dr. Mark Unruh (MU), Chief of the Division of Nephrology at the University of New Mexico, discusses this topic with Dr. Matthew Sparks (eAJKD), eAJKD Advisory Board member.
eAJKD: Why are you interested in this topic? Why is it important to study?
MU: My interest on how hemodialysis interventions impact the quality of life in patients with ESRD dates back to when I was a fellow. I completed nephrology training during the era of the HEMO trial. That trial looked at the effects of dialysis dose and membrane flux on dialysis outcomes. I’ve been interested in trying to improve the quality of life for patients on dialysis ever since then.
eAJKD: What data existed about depression and mental health in hemodialysis patients before this study was initiated?
MU: A large number of descriptive studies exist. These all showed a high rate of depression and a low quality of life among both incident and prevalent hemodialysis patients. We recently published an article using the HEMO trial database demonstrating low mental health scores. Furthermore, we showed that this low mental health score was associated with worse cardiovascular outcomes. The impact of frequent dialysis on depressive symptoms and mental health was recently examined by the FREEDOM Study. This study was an observational cohort using a NxStage dialysis machine. They compared the changes in mental health from a baseline on conventional hemodialysis to 6 months later on the NxStage machine. The FREEDOM Study showed a substantial improvement in depressive symptoms on the NxStage machine over the course of the 6-month observation period.
eAJKD: Can you describe the Frequent Hemodialysis Network Trials?
MU: The Frequent Hemodialysis Network (FHN) Trials are two studies examining the effects of more frequent hemodialysis versus conventional thrice-weekly dialysis. The frequent in-center study examines conventional thrice-weekly in-center hemodialysis versus short 6-times a week in-center dialysis. The nocturnal study examines how nocturnal home dialysis 5- to 6-times weekly compares to conventional home dialysis 3-times a week. Both these trials examine whether an increase in frequency of dialysis improves outcomes. The FHN trials primary outcome was physical well-being and left ventricular mass as measured by cardiac MRI. The frequent in-center study randomized 245 patients, and demonstrated a significant improvement in both left ventricular mass as well as physical well-being using the SF-36 form. The nocturnal study was much smaller with 87 enrolled participants, and demonstrated no benefit from nocturnal dialysis on either LV mass or physical well-being using the SF-36 form.
eAJKD: Can you describe the Beck Depression Inventory (BDI) and the mental health composite of the RAND 36-Item Health Survey?
MU: The BDI is a questionnaire consisting of 21 questions. These questions focus on both depressive somatic systems and more cognitive symptoms. The BDI was selected for this study because it had been used and validated in the hemodialysis population. The mental health composite score and the emotional subscale are both components of the RAND-36. The mental health composite score examines the overall mental well-being of the patient. The emotional subscale examines mainly depression, but also anxiety.
eAJKD: What were the main finding of the study?
MU: We found that frequent in-center hemodialysis improved self-reported mental health as compared to conventional thrice-weekly hemodialysis. However, changes in the self-reported depressive symptoms using the BDI were not statistically significant. We were unable to conclude whether nocturnal hemodialysis improved mental health. There was no significant effect in the Nocturnal Hemodialysis Study, but this may reflect the smaller study size.
eAJKD: How will the findings presented in this article change clinical practice?
MU: I thought that in-center dialysis more than three times a week would lead to more depression and lower mental health. However, other investigators argued that it may actually benefit patients. I believe it’s an important finding that there was no decrement in mental health or increase in depressive symptoms. Patients that are considering using either frequent in-center hemodialysis or nocturnal hemodialysis can take heart in these findings. From this data, it seems that patients, at least over the course of a year, will have a stable or improved mood. This study suggests that nephrologists have a shot at improving the quality of life of our patients, and we should push forward and try to tailor dialysis so that patients have both improved mental as well as physical well-being.