Bulletin de la Dialyse à Domicile

Daily haemodialysis, an underused technique despite its haemodynamic benefits

2025-09-14T17:57:55+02:00

Conventional three-times-weekly haemodialysis causes alternating phases of acute haemodynamic stress during the session (with a risk of hypotension and ischaemia) and chronic overload between sessions (promoting hypertension, pulmonary oedema and left ventricular hypertrophy). The risk is particularly high after the long interdialytic interval. Studies show a correlation between high ultrafiltration rates and excess mortality, suggesting that longer or more frequent dialysis — known as ‘intensive’ dialysis — could better protect the hearts and blood vessels of these patients.

We report our opinion, based on a recent analysis of the literature, regarding the benefits of daily haemodialysis.

Intensive (daily or prolonged) HD improves several parameters:

High blood pressure: meta-analyses and the FHN trial show a significant decrease in blood pressure and left ventricular hypertrophy, with a reduction in the use of antihypertensive drugs.
Per-dialytic hypotension: studies (FHN, RECAP, Murashima) show a decrease in the frequency of hypotensive episodes and improved haemodynamic stability due to lower volume variations.
Myocardium: Conventional HD is particularly associated with myocardial stunning, a factor in ventricular dysfunction and mortality. Daily HD significantly reduces these contractile abnormalities.
Post-dialysis recovery: post-session fatigue, which is common and associated with excess mortality, is greatly reduced by daily HD (LONDON and FREEDOM studies), improving quality of life and psychological well-being.

Despite these benefits, evidence remains limited due to the lack of randomised controlled trials on hard endpoints such as mortality.

Daily home HD appears to be a promising option, facilitated by new devices, although it is currently hampered by the lack of home visits by nurses to puncture the arteriovenous fistula. Nevertheless, it should be offered more widely, particularly to frail patients with refractory hypertension or those who do not tolerate conventional dialysis well.

A rare case of hematologic peritonitis complicating secondary myelofibrosis

2025-09-14T17:57:56+02:00

Peritonitis is a frequent complication of peritoneal dialysis. Its diagnosis is based on clinical signs (pain, cloudy effluent), intraperitoneal hyperleukocytosis (> 0.1×109/L with more than 50% polynuclears), or a positive culture. Although the majority of peritonitis cases are of infectious origin, there are also cases due to non infectious origin, which can lead to the inappropriate use of antibiotics and delayed diagnosis. We report the case of a 78-year-old male patient with a complex haemopathy that combined paroxysmal nocturnal haemoglobinuria, despite treatment with ravulizumab, and essential thrombocythemia, which transformed into myelofibrosis. After the initiation of peritoneal dialysis treatment, he presented with occasionally cloudy dialysis fluid rich in leukocytes (up to 0.442 ×10^9/L), with no evidence of infection (negative cultures and DNA16S PCR, moderate CRP, and an absence of atypical cells). The origin of the intraperitoneal hyperleukocytosis was attributed to myelofibrosis-related blood hyperleukocytosis. The clinical course was unfavorable, leading to palliative management.

This case illustrates the difficulty of managing this complication in peritoneal dialysis patients. Although infectious peritonitis is the most common first-line diagnosis, it is important to consider various differential diagnoses in cases of culture-negative peritonitis, particularly hematological causes (leukemia, lymphoma, myelofibrosis). However, forms with a predominance of neutrophils in the dialysate may simulate an infection. The absence of fever, elevated CRP, and a correlation between blood and peritoneal hyperleukocytosis should help in making a differential diagnosis. Immunophenotyping or molecular biology in the dialysate could refine the diagnosis. This case highlights a possible cause of sterile peritonitis due to myelofibrosis with hyperleukocytosis, and calls for recommendations to be adapted to increasingly complex clinical situations.

Peritoneal Dialysis in an Infant with Severe Acute Kidney Injury: Dialysis Performed In-Flight During a Medical Evacuation in French Guiana – A Case Report

2025-09-14T17:57:57+02:00

We report the case of a 7-month-old infant presenting with severe acute kidney injury in the context of respiratory infection and dehydration who was managed in French Guiana, an isolated territory with limited medical resources. Automated peritoneal dialysis was initiated early, leading to rapid clinical improvement. Due to the necessity of medical evacuation to a referral center, continuity of treatment was maintained aboard a commercial flight from Cayenne to Paris (duration 8 hours 30 minutes) through the performance of three manual exchanges of ambulatory continuous peritoneal dialysis. These exchanges were conducted by a multidisciplinary team (pediatrician, adult nephrologist, nurse) with the assistance of the infant’s mother using an improvised setup that adhered strictly to aseptic protocols. This case highlights the feasibility, safety, and strategic importance of peritoneal dialysis in extreme pediatric settings and constrained environments.