Quality over Quantity: Personalizing dialysis treatment to improve quality of life

Anemia is a common complication in dialysis patients and often treated with iron supplementation and erythropoiesis-stimulating agents. Chapter 2 presented a systematic review comparing iron management strategies between peritoneal dialysis (PD) and hemodialysis (HD) patients. HD patients were more likely to receive intravenous (IV) iron, at higher doses and frequencies than PD patients. Despite these differences, hemoglobin levels and iron status parameters were largely comparable between the two groups. The review highlighted significant variability in clinical practice, emphasizing the need for standardized global policies and further research into the impact of iron strategies on quality of life. Chapter 3 explored the relationship between hemoglobin (Hb) changes and HRQoL. Large declines in Hb were associated with reductions in both physical and mental HRQoL, especially in patients aged 70 years and older. Conversely, increases in Hb did not consistently lead to improved HRQoL. Symptom severity, particularly fatigue and shortness of breath, was higher in patients with declining Hb. These findings suggest that stable Hb levels may be more important than absolute values and support a more individualized approach to anemia management, incorporating patient-reported outcomes (PROs). Chapter 4 assessed the association between iron status, measured by ferritin and transferrin saturation, and PROs in incident dialysis patients. Over a one-year follow-up, no significant associations were found between iron status categories and HRQoL or symptom burden. These results suggest that decisions on iron therapy should prioritize clinical and hematologic parameters rather than aiming to influence PROs directly. Pruritus is a prevalent and distressing symptom among dialysis patients, with limited effective treatment options. Chapter 5 showed that 50–57% of patients experienced pruritus during the first year of dialysis, with 35% suffering from persistent symptoms. Treatment with emollients was associated with worse symptom severity, and other therapies showed no significant impact. Pruritus was consistently linked to reduced physical and mental HRQoL, regardless of treatment. These findings highlight the unmet clinical need for better recognition and management of pruritus. Chapter 6 investigated local inflammatory changes in the skin of dialysis patients with and without pruritus using tape-stripping techniques. Dialysis patients with pruritus had distinct skin biomarker profiles, including increased IL-1RA/IL-1α ratios, lower IL-18 levels and concomitants elevation of IL-1RA and IFN-β, suggesting localized inflammation within pruritus and potential involvement of the opioid pathway. Regardless of pruritus status, dialysis patients exhibited altered cytokine profiles compared to healthy controls. These findings suggest that skin-specific immune alterations may underlie pruritus and provide potential targets for future therapies. Incremental hemodialysis, in which dialysis starts with a reduced frequency and is increased as residual kidney function declines, is an emerging approach aimed at personalizing care. Chapter 7 reviewed the literature on its impact on HRQoL, vascular access, and fluid overload. While theoretical benefits include better patient quality of life and fewer complications, existing studies is scarce, have shown mixed results and raised concerns about fluid overload. Close monitoring and patient involvement are essential for its safe application. Chapter 8 evaluated the long-term effects of initiating incremental versus standard hemodialysis on HRQoL and symptom burden. Using target trial emulation, no significant differences were observed between the two groups. These findings suggest that incremental dialysis may be a viable alternative without compromising long-term patient-reported outcomes. However, further research is needed to explore short-term, on-treatment effects more thoroughly. Chapter 9 examined the risk of vascular access complications in patients starting with twice-weekly versus thrice-weekly hemodialysis regimens. Patients on a twice-weekly schedule had significantly fewer arteriovenous access complications compared to those on a thrice-weekly regimen, while catheter-related complication rates remained comparable. These results support the consideration of twice-weekly dialysis as a means to reduce access-related morbidity.