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December 7, 2001


Emory Researchers Report Elderly Kidney Disease Patients Who Undergo Dialysis in the Morning Live Longer Than Those Treated in Afternoon

Elderly patients with renal failure, who undergo dialysis treatment in the morning, live more than a year longer than patients who receive treatment in the afternoon, according to a group of Emory University researchers. The findings were published in the December 5 issue of the Journal of the American Medical Association (JAMA).

According to the National Kidney Foundation of Georgia, end-stage renal disease (ESRD), more commonly called kidney failure, is an epidemic in the state of Georgia. Georgians with ESRD lose their kidney function at the second highest rate in the United States. The most common causes of kidney disease in Georgia are uncontrolled high blood pressure (38%) and complications from poorly managed diabetes (35%).

Therefore, Donald Bliwise, Ph.D., associate professor of neurology, Emory University School of Medicine, and colleagues decided to investigate the connection between the survival of patients with ESRD and the time of day those patients received dialysis.

"To our knowledge, this is the first time an association between renal failure and time of day treatment has been studied," says Dr. Bliwise. "We believe determining the time of day patients received hemodialysis (HD) is an important, yet frequently overlooked, factor in survival." Most ESRD patients receive hemodialysis (the process to remove toxic wastes from the blood of patients with renal failure) throughout the course of their illness, customarily in the morning or afternoon. The time of treatment is generally based on space availability at a dialysis center or the patient's preference.

The Emory researchers followed 242 patients, ages 60 and older, for 11 years or until those patients died. The patients underwent treatment at 58 dialysis centers across the state of Georgia. Of those patients, 167 were seen during the morning shift and 75 were seen during the afternoon shift. Morning dialysis treatment began between 6 and 11 a.m. Afternoon dialysis treatment began between 11:30 a.m. and 4 p.m.

"Patients who received dialysis during the morning shift survived, on average, for 941 days after entering the study compared to 470 days for patients receiving dialysis during the afternoon shift," says Kathy Parker, Ph.D., R.N., associate professor of nursing, Nell Hodgson Woodruff School of Nursing, Emory University School of Medicine. Dr. Parker is a co-author on the paper, along with Nancy Kutner, Ph.D., professor of rehabilitation medicine, Emory University School of Medicine.

A sleep and aging expert, Dr. Bliwise says the study showed a connection between extra sleep in the morning, during dialysis treatment, and prolonged life of these patients. "In the case of the elderly HD patients, they may simply have found it easier to sleep during the morning shift because they arose as early as 5 a.m. to travel to their dialysis center," says Dr. Bliwise. Previous animal and human studies have shown that sleep is vital for good health, and lack of sleep can cause diseases, such as renal failure, to worsen.

A chronobiologic basis (that is, the effect of time on living systems) for medical disease and/or its treatment has long been recognized. "Chemotherapies for cancer have been reported to have differential effects depending on the time of day when they are administered," Dr. Bliwise adds. "Diseases such as heart attacks and stroke are known to have a greater tendency to occur at certain times of the day. Even symptoms such as headaches and chronic pain often vary during the day. So understanding how other medical diseases, such as renal failure, can be treated over the 24-hour day may carry great practical importance."

The team's multidisciplinary research work was supported jointly by grants from the National Institutes of Health.

The authors point out that their data, indicating apparently positive effects of morning dialysis, were seen in a group of elderly patients. But it is unclear whether patients younger than age 60 would have the same benefits. Randomized clinical trials may be needed to determine the effectiveness of morning dialysis treatments for any age group.

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