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Does this patient have kidney disease that would benefit from daily and nocturnal dialysis?
Background and history of daily and nocturnal hemodialysis
Hemodialysis (HD) evolved from being long and infrequent in the early 1960s to the current standard three times a week regimen. Home hemodialysis decreased in use with the wide availability of facility-based dialysis and introduction of continuous ambulatory peritoneal dialysis (CAPD). The National Cooperative Dialysis Study (NCDS) study established the use of spKt/V ureaas a measure of dialysis adequacy and established the dose of 0.9 as being adequate, later revised to 1.4 in the KDOQI guidelines (2015).
The HEMO and Ademex studies did not show improvement in outcomes by the increasing Kt/V ureain the thrice weekly dialysis or CAPD. Therefore, the interest in alternative dialysis methods or schedules as a potential solution grew. Long hemodialysis (8 hours thrice weekly) best known in Tassin, France, short daily hemodialysis used in several Italian centers and daily nocturnal hemodialysis practiced initially in Toronto, Canada, provided evidence of improved outcomes in observational studies and more recently from RCT's.
How should patients with kidney disease undergoing daily and nocturnal dialysis be managed?
What are the most popular alternative dialysis regimens?
The most popular alternative dialysis regimens (See Figure 1) are:
Short daily hemodialysis (SDHD)
Intermittent nocturnal HD (NHD)
Daily nocturnal hemodialysis
Provide the usual prescription for short daily hemodialysis
The usual prescription for short daily hemodialysis is summarized in Figure 2.
5-7 days per week
1.5 to more than 3 hours.
In the dialysis facility (in-center) or at home.
Qb >350 ml/min, Qd80-800 ml/min.
Dialysate composition – same as conventional HD (CHD).
Exception: The NxStage machine:
Qb >250 ml/min
Qd 130-200 ml/min (volume 15 to 35L)
Provide the usual prescription of nocturnal hemodialysis
The usual prescription for nocturnal dialysis is also shown in Figure 2.
3-7 days per week
3 nights a week in center or at home
every other night at home
5-7 nights at home (daily NHD)
Qb 200-300 typical 250 ml/min (in children Qb100-200) (Higher flow can be used as well) (A single-needle system provides extra safety as accidental disconnection can trigger an air detector alarm)
Qd 100-800, typical 300 ml/min
Dialysate composition:
Na+ similar to CHD – typical 140 mEq/L
K+ 1-3 mEq/L typical 2 mEq/L
30 mEq/L or mmol/L for 5-7 nights per week
35 mEq/L or mmol/L for 3-4 nights per week
Exception: NxStage machine:
Lactate as the base 40-45 mEq/L.
Calcium 2.5-3.5 mEq/L or 1.25 – 1.75 mmol/L.
Lower if on calcium-based phosphate binders.
Higher (4.5 mEq/L or 2.25 mmol/L) post parathyroidectomy or during pregnancy as needed (see below) or hungry bone disease
Sodium phosphate (Fleet enema®) 30-135 ml per 4.5L acid or bicarbonate concentrate
final phosphate concentration of 1-3 mg/dl or 0.3-0.9 mmol/L.
The typical volume of ultrafiltrate removed per day is approximately one to two liters, but larger volumes are well tolerated. Patients weigh themselves daily to maintain dry weight, which is defined as normotension without the need for antihypertensive medications or edema.
Dialyzer Membrane
Any dialyzer membrane can be used, including smaller surface area dialyzers. Although there are no published data, most centers use high flux dialyzers.
Up to 200 ml of Fleet enema® have been used in cases of hungry bone syndrome or during pregnancy.
Instructions for adjustment of dialysate calcium
Use either concentrates with higher calcium as needed or:
Add calcium chloride powdered 'spikes' (slight increase in cost)
easier to fine tune composition without frequent home dialysate deliveries
15 mL of powder increases dialysate calcium by 1 mEq/L (0.5 mM)
usual changes by 2-3 ml
use small volumetric cylinder for measurement (empty syringe barrel)
Calcium in bicarb concentrate
The patient should be warned against addition of calcium chloride into the bicarbonate bath as it will cause:
precipitation of calcium carbonate
high parathyroid hormone (PTH)
bone disease
Dialysate calcium when high Qd
If high Qd is chosen on NHD requiring two dialysate jugs.
The prescribed amount of calcium additive needs to be added in each jug.
Instructions for adjustment of dialysate phosphorus
Sodium phosphate (Fleet enema®) 30-135 ml per 4.5L acid or bicarbonate concentrate as needed
Adjustments usually by 20-30 ml
It does not precipitate in the 'acid' concentrate due to low pH
Phosphate may not be added during the dialysis after a long interdialytic interval
Clinical pearls on phosphate control
The need for phosphate additive into the dialysate should be based on the pre- and post-dialysis serum phosphate.
On daily NHD both values can and should be normalized
On intermittent NHD post-HD phosphorus may have to stay slightly low to prevent predialysis hyperphosphatemia
Fleet enema additive of 80-100 ml/jug prevents phosphate removal. Higher doses provide phosphate addition to serum
Doses even above 200 ml/jug have been used in 'hungry bone syndrome' or pregnancy
Amount of phosphate removed or gained during dialysis depends on dialysis length
higher amount of additive is needed to address deficiencies if dialysis is shorter
Dialysis machines
Most of the available dialysis machines are suitable for intensive hemodialysis.
Several machines have been designed or modified for daily or/and home hemodialysis.
Most of the characteristics are aimed to simplify the dialysis technique for the use at home by the patients.
The majority of dialysis machines in use at home are equipped with an ultrafilter for the production of ultrapure dialysate.
The NxStage system
Needs to be mentioned separately
Available in the US and several other countries.
As currently used in most facilities, it provides lower total dialysate volume of about 20-35 L per treatment. Does not have a proportioning system but needs ready-made dialysate.
in plastic bags or
produced by the Pureflow® water system
can provide 60 L per treatment if desired (usual dialysate volume is 20-25 L).
provides water treatment and produces ready-to-use dialysate
dialysate volume dictates the dialysis cost and is therefore is affected by the dialysis reimbursement constraints.
The benefits of daily hemodialysis compensate for the possible negative effects of lower small molecule clearance associated with the low dialysate volume.
Increased dialysis length, while maintaining low total dialysate volume, provides higher phosphate and middle molecule removal but obviously almost the same small molecule removal.
Desirable attributes of a home dialysis machine
Some of the desirable attributes of a home dialysis machine incorporate:
low noise level
an easy-to-see display at the level of the sitting patient
large fonts
dimming options for night-time use
use of a bicarbonate cartridge/bag
easy disinfection
low heat emission
availability easy to use single needle system
low water and electricity consumption
easy starting and terminating the treatment
back-up battery to protect from power failure
Water treatment
A portable water system is needed for home hemodialysis
Water reverse osmosis (WRO) machines and
Carbon filter or
DI tanks.
Water softener when well water is used.
Routine water and machine management should include water cultures monthly as well as endotoxin analysis (Table 1).
Table 1.
|Endotoxin level (EU/ml)
|Bacterial growth (cfu/ml)
|Association for the Advancement of Medical Instrumentation (AAMI)
|< 2
|< 200
|Canadian Standards Associations (CSA)
|< 2
|< 100
|International Organization for Standardization (ISO)
|< 0.25
|< 100
Periodic water analysis needs to be done 2-3 times a year.
Water treatment for the NxStage machine
The NxStage system does not need water treatment if the dialysate is in bags. The PureFlow® system can produce ready dialysate.
Electricity and drainage
A dedicated electrical circuit is needed at home as well as an access to a drain.
A dedicated GFI (Ground Fault Interrupter) breaker, wire and hospital grade receptacle for the dialysis machine must be installed from the main panel to the dialysis room.
The GFI amps and the wire size depend on the machine consumption (check manufacturer data sheet). An existing outlet is acceptable for the Water Reverse Osmosis machine
Water supply
The pressure of the incoming water must meet the WRO system requirements.
There must be both hot and cold water sources, usually taken from under the sink, connected to a blending valve and temperature gauge.
Where no city water exists, well water can be used to perform dialysis. Usually well water is hard and softeners are required. Chlorine is added to city water unlike well water and therefore a carbon filter is useful. The use of the carbon tanks is still useful also for well water as it is rich in iron removed by the carbon tanks.
The drain pipe is connected to the closest sink. It is important to pour bleach in the drain pipe on a monthly basis to prevent the buildup of protein inside the drain pipe. Water leaks may occur from the dialysis machine or the water treatment system.
Patients are advised to get plywood sheets completely covered with vinyl or a sheet of plastic. The dialysis machine will be placed over the covered plywood in case water leakage occurs from the hydraulic system of the machine. Water is kept within the frame parameters. Two water sensors should be placed on the plywood by the machine side where the water may leak.
Remote monitoring of the dialysis machine
Live remote monitoring of the dialysis machine during the night, through a telephone or internet connection, is employed by some dialysis centers. An observer calls the patient or the emergency services if machine alarms remain unattended. There is no consensus on the importance of such monitoring.
Remote monitoring is not considered mandatory in most jurisdictions. If it is available at a reasonable cost, it can provide reassurance to some patients during the initial period of nightly home dialysis and provides information about dialysis treatment compliance. Such information, however, can also be obtained through intermittent connection and interrogation of the dialysis machine.
Solute removal
Small molecules (urea)
The use of the weekly standard Kt/V (stdKt/V), as described by Gotch, has evolved into the preferred measure for dialysis dose for the alternative dialysis schedules. It is based on the predialysis mid-week urea levels. It therefore favors the frequent or continuous forms of dialysis (predialysis urea is lower). A stdKt/V of 2.3 represents the current KDOQI recommended dialysis dose (2015). The calculation of stdKt/V is more complex (14) than the use of the currently popular urea reduction ratio (URR).
Phosphate removal correlates well with the total length of dialysis per week. Therefore, SDHD for more than 2.5 hours daily and NHD are effective in terms of phosphate removal, resulting in fewer phosphate binders being required. No phosphate binders are needed for 6X/week NHD; neither for 70% of patients on every other night home NHD. Phosphate additives are needed in the dialysate of more than 50% of patients on NHD when done 6 nights a week. Successful removal of phosphate allows for liberal phosphate intake (see mineral metabolism below).
Large molecules
Removal of large molecular weight solutes depends on membrane flux, use of convection and most importantly on dialysis duration. The amount of beta-2 microglobulin removal on frequent NHD is four times as high as on conventional HD. This corresponds to the four times longer duration of NHD dialysis compared to conventional HD. Daily NHD and daily hemodiafiltration are associated with lower serum predialysis beta-2 microglobulin levels. Effects on highly protein bound molecules are minimal.
Urea kinetics in NHD
Formal urea kinetic modeling may not be accurate on daily and especially on NHD. Urea generation may not be constant on NHD due to the longer dialysis during a fasting state. There are also amino acid losses into the dialysate that can potentially affect urea generation. This may result in URR overestimation by 7-15%.
Dialysis access
AV fistulas, grafts and catheters have been used successfully for daily and NHD. AV fistulas are encouraged.
AV access
The buttonhole technique of fistula cannulation popularized by Twardowski has been widely used for home hemodialysis. It involves using the same site for successive cannulations. "Blunt" needles are utilized after the buttonhole track is established using sharp needles for 1 to 2 weeks. Before cannulation, the fistula and surrounding skin is cleansed with chlorhexidine gluconate (0.5% in 70% alcohol) or providone-iodine solution. Scabs are covered with an alcohol pad for 5 minutes and then removed using a sterile needle.
The advantages of this technique include diminished or no pain and the predictability of a successful cannulation. A high incidence of systemic infections has been encountered with the use of the buttonhole technique, mainly involving Staphylococcus aureus. The resulting bacteremias can lead to metastatic infections and significant morbidity, and even mortality. Meticulous aseptic techniques, especially the application of a small amount of mupirocin on the site after dialysis, have prevented this complication. Some have called for the abandonment of the buttonhole technique due to the risk of systemic staphylococcal infections. Since starting the use of local mupirocin more than 10 years ago, we have had no patients experiencing infections due to the buttonhole technique. The buttonhole technique should not be used for grafts. A technique called rope-ladder is usually employed, where a different hole is used with every dialysis.
Although observational studies suggested equal or decreased vascular access complications during daily dialysis, the Frequent Hemodialysis Network trial (FHN), a randomized controlled trial (RCT) sponsored by NIH and CMS, reported increased access intervention in the daily HD patient group as compared to controls. This does not necessarily imply decreased access survival.
Safety is of paramount importance when using AV access, especially during the night on NHD. Disconnection of the "venous return" needle may not be sensed by the dialysis machine, leading to exsanguination. To ensure the safety of the procedure, adequate taping of the needle and anchoring of the blood tubing are essential. An additional alarm mechanism is highly recommended (moisture sensor) to awaken the patient in the case of blood extravasation from the access site. Most centers use an inexpensive non-disposable "enuresis alarm" for this purpose.
A blood leak detector system has become commercially available for this purpose, using disposable sensors attached to a non-disposable alarm device (RedSense Medical AB). Furthermore, a dialysis machine has become commercially available (Fresenius Medical Care, Waltham, MA), which incorporates a wireless sensor for blood leak, leading to blood pump arrest.
The use of single needle dialysis technique is encouraged for patients on NHD. It can provide adequate blood flow while it decreases the likelihood of complications related to accidental needle dislodgement and bleeding during hemodialysis.
Dialysis catheters can be used successfully for intensive hemodialysis. As low blood flow is adequate for NHD, even a poorly functioning catheter is often adequate. The use of pre-perforated dialysis catheter caps is of significant importance during NHD. There are at least three products available: The InterLink® (Becton-Dickinson, Utah, USA), the TEGO® (ICU Medical, CA, USA) and the Swan-Lock® (Codan, Lensahn, Germany) systems have been used.
Dialysis is performed without removing the catheter caps. Resistance to flow provided by these attached caps (dissimilar among the different brands) does not prevent attaining adequate dialysis, as low blood flow is adequate for long hemodialysis. These attachments prevent air embolism in the case of accidental disconnection of the tubing from the dialysis machine. Bleeding is also prevented if the "arterial" but not the "venous" port is disconnected. Therefore, meticulous attention should be given to the proper taping of the tubing to the catheter to prevent disconnection, especially of the venous port.
The local instillation of 2 mg of alteplase (tissue-type plasminogen activator or tPA) has been very successful in restoring adequate blood flow in obstructed catheters due to thrombin. The instillation of lyophilized tPA has been practiced successfully by patients at home.
The approach to the prevention of catheter thrombosis is variable in different centers. Some centers use a small dose of warfarin to prevent catheter thrombosis, while others use prophylactic tPA. The initial warfarin dose is usually 2 mg/day. For patients with recurrent thrombosis, the dose is increased by 1 mg until patency is maintained, providing the INR remains below the levels that the physician considers safe -usually below 2. However, a prospective randomized controlled study did not find the use of low dose warfarin useful in preventing catheter dysfunction. The risk of bleeding, vascular calcification related to the use of warfarin, and the negative trial cited should be considered for individual patients.
The incidence of catheter-induced bacteremias with nocturnal hemodialysis is relatively low (approximately 0.35 to 1.5/1000 days). A recent review by Hayes of 98 patients on NHD using catheters during a study period of 6.5 years, found that 64.4% of patients developed bacteremia with a rate of 1.12 episodes per 1000 days. The most common organism was staphylococcus epidermidis (51.4%). At our center, patients with fever and chills during the initiation of dialysis but without severe symptoms, such as hypotension, usually draw blood cultures at home and begin empiric treatment with intravenous antibiotics (usually 1 gm of Vancomycin and 1.5 mg/kg of tobramycin if they have previously tolerated such agents). The treatment is subsequently modified based upon culture results and continues for two weeks. If appropriate, based upon culture results, continuation of treatment with cefazolin rather than vancomycin is encouraged. If the infection recurs (in our experience usually one month later), the catheter is replaced over a guidewire after restarting or continuing antibiotic coverage. A different site should be chosen if an exit site is present.
Many bacteremias resolve successfully with antibiotics. We immediately remove the catheter with severe sepsis especially if associated with hemodynamic instability or suspicion of metastatic infection. The infection rate and survival of the catheters on nocturnal hemodialysis may be better than conventional hemodialysis, but data from randomized controlled studies are absent.
Practical aspects
One or two pairs of buttonholes are usually created on each fistula. In the latter case the pair of buttonholes is rotated after each hemodialysis session. If a buttonhole is not functional, another buttonhole is created. This can be done by the patient, or by the nurses in the dialysis center, which requires one or more patient visits.
The "BioHole device" (Nipro Co., Osaka, Japan) has been described for the creation of the buttonholes. It involves the insertion of a peg into the fistula hole after the needle is removed, thereby keeping the buttonhole open until the next hemodialysis. This routine is continued for the first 14 days of buttonhole creation, followed by the use of the routine "blunt" needles.
Some patients need sharp needles to cannulate the buttonhole as the healing process is fast and the buttonhole is not functional even 1 day later.
Routine anticoagulation may be used both for daily or nocturnal hemodialysis. Either unfractionated (1000 units per hour) or low molecular weight heparin (LMWH) can be used similar to that used in conventional hemodialysis. LMWH has been used successfully with Nocturnal Hemodialysis. In the case of heparin-induced thrombocytopenia (HIT), argatroban and danaparoid have been successful alternatives, however the cost is prohibitive.
Intensive hemodialysis provides better uremic control compared to CHD. Fewer dietetic restrictions are needed in the case of daily hemodialysis. There are no dietetic restrictions while on daily NHD for most of the patients.
Need for supplements
NHD leads to removal of 10-15 gm of aminoacids per session. Therefore, the patients are advised to follow a high protein diet; no ill-effects have been described related to the amino acid losses. The serum amino acid concentration seems to improve on NHD.
Water soluble vitamins are recommended for the patients on intensive hemodialysis. Although there is no adequate data available, most centers suggest two multivitamin tablets for patients while on NHD. Some clinicians suggest administration of vitamin C on top of the amount available in the multivitamin preparation. We have prescribed vitamin C 500 mg daily in selected patients with low serum vitamin C levels. The vitamin C assay is sensitive to suboptimal handling of the sample and this leads often to falsely low values.
Patient selection
Intensive hemodialysis can be offered to alleviate patient symptomatology, improve outcomes and to promote patient independence and rehabilitation.
Symptomatic patients
Symptoms related to uremia, dialysis or comorbidities can improve on intensive hemodialysis. Patients with left ventricular hypertrophy (LVH), refractory heart failure, uncontrollable hypertension, ascites, malnutrition, amyloidosis or neuropathy have been treated successfully with short daily or nocturnal hemodialysis. Facility-based SDHD and NHD three nights a week have been used to treat patients who are failing on conventional HD. Hemodynamic instability and low BP during dialysis is not a contraindication but rather an indication for NHD. Daily NHD is often the only hemodialysis schedule that can be tolerated by very hemodynamically compromised patients.
Healthy patients wishing to improve their quality of life
Patients choose intensive home hemodialysis to improve quality of life and enhance physical and vocational rehabilitation. Patients who cannot be transplanted, want to work, live away from dialysis facilities or have difficulty adjusting to the disciplined life of conventional facility-based HD, should be encouraged to choose home hemodialysis. Other good candidates include patients who need to transfer from CAPD to HD.
Many dialysis centers have adopted a "Home First" policy, where patients are educated and encouraged to choose a home-based dialysis method, either PD or home hemodialysis. If patients with chronic kidney disease (CKD) are educated early enough about the benefits of home dialysis, recruitment to home dialysis is more successful than for a prevalent patient on facility-based dialysis. Resources to help patients and their families to choose the appropriate home dialysis modality have been created (e.g., MATCH-D; available at www.homedialysis.org/match-d).
Detailed aspects of patient selection
Patients with severe cardiomyopathy associated with hypotension have been dialysed using daily NHD at home despite predialysis systolic blood pressure (BP) lower than 100 mm Hg. Most of these patients improved over time with progressive decrease of their extracellular fluid volume (ECFV). This improvement, in most cases, is striking. A common clinical dilemma is the following: in the presence of hypotension, should preference be given to fluid removal or to maintenance of treatment with RAS inhibitors and beta-blockers? Although sufficient data is not available, we have found that fluid removal and temporary discontinuation of the medications is most effective.
Need for helpers
Currently no firm policy exists regarding the need for a partner for frequent or long home hemodialysis. There have been many patients who dialyzed on NHD without the presence of a partner. However, hemodynamically unstable patients, especially those on shorter dialysis schedules, may require the presence of a partner. Several patients who cannot be trained for home hemodialysis have been dialysed with the help of unpaid (usually family members) or paid helpers. The expense for paid helpers is usually borne by the patients or their family. Helpers without previous dialysis knowledge or experience have been successfully trained and represent the majority of the paid helpers in our institution.
Contraindications to intensive home hemodialysis
Patients with poor insight, untreated psychosis, or uncontrolled seizure disorder or brittle DM with frequent hypoglycemias may not be able to do home HD. Furthermore, patients who are unwilling and unable to learn how to do dialysis or handle emergencies are obviously poor candidates. The presence of a helper who has been trained to perform dialysis is a good alternative. Inability of the patient or the helper to communicate with the nurse, the physician on-call or the Emergency Medical Services due to language barriers would also rule out home hemodialysis. Contraindication to systemic anticoagulation is the only absolute contraindication and applies solely to NHD.
Barriers to home hemodialysis
There are several patient-related barriers to home HD. Even if patients have the willingness and ability to learn. These included difficulty with self-cannulation, the fear of a catastrophic event, and the burden on the family.
Barriers related to financial reasons are significant. These include inadequate reimbursement for more frequent dialysis as well as expenses incurred by the patients dialysed at home. Patient borne expenses include electricity, water, sewage, and waste disposal costs. The amount incurred by patients in our center is as high as $1500-2000 per year.
In a few instances, the patient is unable to master the fistula cannulation technique. It is our opinion that using a dialysis catheter and persevering with an intensive hemodialysis at home rather than switching to facility dialysis is the preferred approach. There is insufficient evidence supporting this approach.
Training for home hemodialysis
Ideally, incident patients who are candidates for home HD should be kept separate from the prevalent hemodialysis patients until the training starts, as they often settle on CHD and do not choose home HD. The use of a "transition unit" where patients start on dialysis away from the rest of the established dialysis patients has been practiced in some centers with considerable success. The patient adaptation can be smoother and the choice of home dialysis more likely. The patient or helper undergoes a graded learning program co-ordinated by a dedicated allied staff including training nurses, technologists, pharmacists, dieticians, social workers and physicians. The patients trained for nightly dialysis should dialyse once or twice at night in the center after the completion of their training. This approach has not been universally practiced.
Remote monitoring of the dialysis machine, if available, for 3 months, increases the comfort of patients. A home visit by the training nurse on the first day of discharge home is useful. Some programs conduct a formal assessment of the patient/helper at the end of the training, which leads to "certification of competence." A yearly recertification is advised by some centers.
The home dialysis patients are encouraged to have adequate home insurance to cover costs related to dialysis-related damage, usually water leaks. Some centers would not allow home HD to proceed without home insurance coverage.
Home dialysis patients are requested to do laboratory tests monthly and visit the dialysis clinic every 1-4 months depending on their clinical stability. Post-HD laboratory tests are recommended on the following: potassium, calcium, and phosphorus. The rest of the laboratory tests are similar to those for CHD patients.
The patient/helper training is done while the patient is dialysed either thrice weekly or daily. In the case of daily dialysis, the training time is shorter. Home dialysis training lasts 5-8 weeks. Fistula training is a significant component and adds to the length of the training.
Other aspects of training
Above and beyond the obvious aspects of training for home hemodialysis, most centers train patients how to collect blood and centrifuge the samples to be delivered to the laboratory, self-administer antibiotics and intravenous iron, and collect water samples for testing.
Among the home supplies the following should be considered: Antibiotics enough for treatment for a small number of days (Vancomycin and Tobramycin or ceftazidime in the presence of residual kidney function, are supplied in our center), blood culture bottles, blood collection tubes, intravenous iron preparation (Venofer® is used in our center), Kayexalate® and lyophilized tissue plasminogen activator (Alteplase-TPA) for some patients with dialysis catheters, especially those living away from the center.
Parathyroid hormone testing is challenging as the PTH levels decay quickly in the tube. This is particularly problematic in the case of home NHD where the sample is harvested in the evening. It has been observed that if the blood is collected in tubes containing EDTA and stored in the refrigerator overnight without centrifugation the accuracy of the assay is acceptable. Alternatively, PTH is measured during clinic visits.
The timing of the monthly laboratory tests varies among the centers. As the main risk on daily NHD is low rather than high levels of solutes, we recommend that the laboratory tests are done after a few consecutive nights on dialysis.
What happens to patients with kidney disease undergoing daily and nocturnal dialysis?
Clinical outcomes of intensive hemodialysis
Blood pressure
All intensive HD schedules have been reported to improve BP control. Long intermittent HD for 8 hours 3 times a week, as practiced in Tassin, France for more than 40 years, improved BP control with few or no medications. Decrease in the post dialysis weight and low salt diet were the cornerstones of this approach. BP control with fewer medications or no medications on SDHD and NHD was described in several studies. Improvement in BP control was confirmed in two RCTs: The Alberta trial on NHD and the FHN trials on both SDHD and NHD.
How to control blood pressure
Improvement of BP on the intensive HD regimens is achieved initially through the progressive decrease in post dialysis weight. In some patients, there is a delay of a few weeks in achieving excellent BP control (the "lag phenomenon"). This is consistent with evidence suggesting that vasodilatation is one of the late mechanisms responsible for hypertension control on NHD.
Our approach to BP control on daily HD is similar to the approach followed by the Tassin group. The post dialysis weight of the patients is decreased progressively until BP is well controlled. Antihypertensives are discontinued progressively. As the decrease in the post dialysis weight often leads to reflex tachycardia, beta blockers are discontinued last. Aggressive decrease in the dry weight may accelerate residual renal function loss as shown in the FHN trial.
Regression of LVH
Left ventricular hypertrophy (LVH) mainly in the form of dilated cardiomyopathy affects 70-80% of the dialysis population and has been used as a surrogate for patient survival in both the renal and general population. Regression of LVH has been described in several observational studies on SDHD and NHD but not as conclusively on intermittent long hemodialysis.
Regression of LVH has been used as a surrogate outcome of patient survival in two RCTs. It was detected after 6 months on NHD in the Alberta study when compared to conventional HD. In the FHN trial, frequent hemodialysis, as compared with conventional hemodialysis, was associated with favorable results with respect to the composite outcomes of death or change in left ventricular mass and death or change in a physical health composite score. The regression of LVH was proportionate to its severity. The NHD arm of the FHN trial did not confirm a statistically significant LVH regression in this population despite a positive trend. This arm of the trial was unable to recruit the initially planned number of patients and also accepted a high number of incident patients with higher residual kidney function. These two factors have been offered as a possible explanation for the lack of significant results.
Improvement in cardiac function and endothelial function
Impressive improvement of the ejection fraction of patients with cardiomyopathy on NHD has been described in an observational study. There was improved endothelial function and decrease in sympathetic tone.
Patients on dialysis are characterized by impaired endothelial function, autonomic system imbalance characterized by increased sympathetic tone, leading to vasoconstriction and decreased heart rate variability. The number and function of the progenitor endothelial cells are decreased. These parameters have been associated with increased cardiovascular morbidity and mortality in the renal as well as in the general population.
Improvement of endothelial function was seen on NHD. Norepinephrine levels decreased and the post-ischemia vasodilatory response of the radial artery improved. Peripheral vascular resistance measured by echocardiographic techniques also decreased. Furthermore, the number and function of endothelial progenitor cells improved after conversion from CHD to NHD. Endothelial stem cells harvested from NHD patients improved the ischemic rat hind leg ischemia as compared to poor response to cells derived from patients on CHD.
The FHN trial confirmed that the vagal tone increases and heart rate variability increases on frequent HD.
Some of the improvements in endothelial function correlated temporally with improvement of serum phosphate levels, supporting the hypothesis of cardiovascular phosphate toxicity. Other benefits observed on NHD included improvement in baroreflex function, exercise duration and capacity and improvement in muscle cell biology.
Quality of life
There are several observational studies reporting improved quality of life on intensive hemodialysis including long intermittent hemodialysis, SDHD, and daily NHD. There are two RCTs published that examined the treatment effects on QOL. The Alberta study randomized 52 patients to either CHD or home NHD for 6 months. The improvement in QOL on NHD did not achieve statistical significance (p=0.06). Several kidney-specific quality of life domains showed significant improvement on NHD (p=0.01).
The FHN trial randomized 250 patients to CHD or facility-based SDHD. There was a significant improvement of the co-primary composite outcome of death or change in the physical-health composite score of the RAND 36-item health survey. Such an improvement was not seen in the nocturnal arm of the trial. However, there was a trend for improvement in the health survey in both study and control groups of patients. This may be related to the benefit of initiation of dialysis, as most of the patients were incident patients, or to the change in the dialysis location from in-center to home.
Residual kidney function
In the FHN trial the patient residual renal function decreased more rapidly in the nocturnal arm of the trial compared to controls. It should be noted that the patients recruited for the NHD arm of the trial had higher residual kidney function than in the daily HD arm.
Mineral metabolism
Phosphate control
Hyperphosphatemia is a significant problem in CKD and has been linked to both CKD metabolic bone disease as well to vascular calcification, increased morbidity, and mortality. As described above, SDHD is associated with improved phosphate control if the duration of dialysis per week exceeds the time on conventional HD. Three-hour daily dialysis has been recommended. This was confirmed on the FHN trial, a NIH sponsored RCT. Phosphate control is excellent on daily NHD resulting in the discontinuation of phosphate binders in all patients. Moreover, there is the need to add phosphate into the dialysate in about 75% of the patients. Three times a week or every other night NHD is also effective with 80% of the patients not needing phosphate binders. Obviously, phosphate intake is less restricted on SDHD and unrestricted on NHD. High phosphate intake is encouraged on daily NHD.
Calcium balance
Calcium balance can be negative on long hemodialysis. Calcium loss through ultrafiltration of the ionic calcium component is proportionate to ultrafiltration volume, therefore proportionate to the salt and water intake. Most patients on intensive dialysis use lower dose or no calcium-based phosphate binders and also have low GI calcium absorption due to low serum vitamin D levels. All the above may lead to negative calcium balance. Therefore, dialysate calcium needs to be higher than on conventional hemodialysis to maintain calcium balance.
In most patients on daily NHD dialysate calcium needs to be greater than 3 mEq/L (1.5 mmol/L). Dialysate calcium should be adjusted aiming to maintain serum post-dialysis calcium higher that the pre-dialysis value (to accommodate the increase in the total calcium concentration due simply to the hemoconcentration and effect on the albumin-bound calcium).
Parathyroid hormone (PTH)
PTH levels are a function of dialysate calcium levels. Usually adjusting the dialysate calcium levels will allow the PTH to be within the desirable range. There is no information as to what the ideal PTH should be on intensive hemodialysis; therefore, KDOQI guidelines should be followed. Changes in alkaline phosphatase are useful in selecting the appropriate PTH levels. In the absence of hyperphosphatemia, post-dialysis transient hypercalcemia necessary for control of elevated PTH levels may be safe, especially in patients without evidence of arterial calcifications. In the presence of vascular calcifications, hypercalcemia should probably be avoided and the use of calcimimetics or parathyroidectomy should be considered.
Phosphate additive
The need for phosphate additive into the dialysate should be based on the pre- and post-dialysis serum phosphate. Ideally laboratory tests should be done on a steady state while on daily HD (after 3 consecutive nightly sessions) but after the longer interdialytic interval on intermittent dialysis. The timing of the testing should be taken into account in the dialysate composition prescription.
Phosphate should not be added in most patients during dialysis after a long interdialytic interval. The amount of Fleet enema can be safely increased above the above recommended levels (Table 1) in cases of bone formation (post parathyroidectomy, while on calcimimetics especially in the presence of high bone-derived alkaline phosphatase or during pregnancy). Phosphate does not precipitate with calcium in the 'acid' concentrate due to the presence of acid pH.
Fleet enema doses more than 200 ml per jug have been occasionally employed. In the case of long intermittent hemodialysis it is often difficult to normalize both pre- and post-dialysis P because correction of post-dialysis hypophosphatemia can lead to high pre-dialysis P values. This can be resolved by accepting serum pre-dialysis phosphate up to 4.5 mg/dL (1.5 mmol/L) while ignoring mild post dialysis hypophosphatemia.
Increasing levels, or lack of correction of high PTH levels, or are increasing or not decreasing elevated alkaline phosphatase levels may be suggestive of inadequate dialysate calcium levels.
Flexible calcium dialysate composition can be achieved through calcium chloride powdered additives; 15 mL of powder increases dialysate calcium by 1 mEq/L (0.5 mmol/L).
This allows the continuous adjustment of the dialysate composition for home hemodialysis without the need to deliver a new dialysate supply to the home of the patient. The patients in our center use a volumetric cylinder (empty syringe) to measure the volume of the calcium chloride powder. The mistaken addition of calcium chloride into the bicarbonate bath will cause precipitation of calcium carbonate and lead to hypocalcemia, high PTH and increased levels of alkaline phosphatase. Dialysate calcium concentrations more than 4 mEq/L or 2 mmol/L have been occasionally needed in cases of 'hungry bone' syndrome.
Sleep disorders are very common and under-recognized in patients at all stages of CKD. The most common disorders include sleep apnea, insomnia, excessive sleepiness, restless leg syndrome and periodic limb movement disorder. The prevalence of sleep apnea in the dialysis population is higher than 50%. Conversion of patients from conventional hemodialysis to daily nocturnal hemodialysis was associated with a significant decrease in the apnea-hypopnea index and an improvement in the hypoxemia during sleep. Similar effects were observed on nightly peritoneal dialysis (APD). The effect of SDHD on sleep disorders is unknown. In a recent study home hemodialysis was associated with improvement in the severity of the restless leg syndrome.
Insomnia is not uncommon during the early period on nocturnal hemodialysis. The judicious use of short acting sedatives has been used successfully in some patients. This can be considered in the presence of a helper at home, who would be able to react to dialysis machine alarms.
Sleep-mechanistic analysis
Sleep apnea is caused by the destabilization of central ventilatory control and upper airway occlusion during sleep as well as by enhanced ventilatory sensitivity to hypercapnia. These abnormalities seem to improve with the conversion to nocturnal hemodialysis. Upper airway occlusion can be caused by fluid overload and interstitial edema in the upper airway. Conversion of ESRD patients from CHD to NHD was associated with an increase in pharyngeal cross-sectional area, possibly due to improved fluid removal. Similarly, conversion from CAPD to nocturnal peritoneal dialysis is associated with reduced pharyngeal narrowing as measured by magnetic resonance imaging.
In observational studies, conversion of patients from CHD to SDHD was associated with increased body weight, nPNA serum albumin levels, and arm muscle area. Anecdotal experience with patients on both regimens suggests increase in appetite and at times very significant weight gain. Hemodialysis is associated with amino acid losses in the dialysate, which would be higher on more frequent and long hemodialysis. No negative effects have been reported but a relatively higher protein diet is recommended in these patients. Long term nutritional stability was reported on long hemodialysis while decrease in body weight with time has been associated with the use of CHD. The FHN trial did not show significant change in body composition on frequent HD. Nonetheless, more frequent dialysis regiments liberate dietary intake of salt, water, potassium, phosphate and protein. Although potassium intake is not restricted, the amount needs to be relatively consistent. The dose of multivitamin preparation is increased to two tablets daily. However, there has not been any evidence of vitamin deficiency.
Erythropoiesis-stimulating agents and iron administration
The reported effects of SDHD and NHD on anemia and the dose of erythropoiesis stimulating agents (ESAs) have been variable. Several observational studies reported increasing hemoglobin levels as well decreasing need for ESA. The three RCTs published to-date failed to demonstrate the effect of daily or nocturnal hemodialysis on anemia control. The trial population characteristics and the short time on the studies may be relevant to the results.
In our center, a decrease in the dose of ESA by about 30% was observed less than 1 year after the initiation of NHD. About 25% of the patients on NHD in our center are off ESA. In vitro, growth of erythroid (BFU-E) and granulocytic (CFU-GM) colonies was superior when cultured with NHD plasma compared with conventional HD plasma, supporting the beneficial effect of intensive dialysis. Most centers train patients on home dialysis to self-administer intravenous iron usually in the form of iron dextrose (Venofer®).
The first dose of Venofer® is administered in a facility capable of treating anaphylaxis. We did not encounter significant adverse reactions to Venofer® administration at home over the last 15 years.
The dose of intravenous iron is similar to CHD. An increased dose is often needed during pregnancy. Most patients are given Venofer 100 mg intravenously twice a month. Several patients off ESA have hemoglobin levels above 13 gm/dL or 130/L. The need to replenish low iron stores in these patients with hemoglobin above the DOQI guideline levels off ESA is unclear.
Effect on reproductive biology
Fertility is decreased in ESRD and pregnancy is often associated with poor outcomes. Intensive HD has been used over the last few years to improve fertility rates and pregnancy outcomes. Improved hormonal function has been described on daily hemodialysis. Several successful pregnancies have been reported on daily NHD; therefore, intensive hemodialysis has been advocated prior to and during pregnancy. Use of daily NHD is the preferred dialysis modality during pregnancy, based only on observational studies and one patient cohort comparison. Alternatively, other forms of intensive hemodialysis should be used. Patients dialyzed for more than 36 hours per week had the highest rate of live births (85%).
The need for increased amounts of calcium and phosphorus in the dialysate has been observed and is likely related to the growth of the fetal skeleton. One should be guided by serum pre- and post-dialysis calcium and phosphorus as well as PTH. If the deficits are not corrected, elevated levels of PTH and alkaline phosphatase will be evident.
The need for ESA and iron supplements during pregnancy is higher. The anemia may be partially related to increased intravascular volume expansion associated with pregnancy which is accommodated by the dialysis prescription as dictated by clinical parameters.
Some patients develop hypertension during pregnancy. Pharmacological treatment is similar to that of pregnant women with normal renal function. Labetalol, alpha methyldopa, and other appropriate medications have been used.
The safety of aggressive ultrafiltration for blood pressure control is unclear. Judicious use of ultrafiltration in the presence of symptoms of breathlessness or significant edema is reasonable. The effect or ultrafiltration on placental flow is not known. Most clinicians tend to avoid using ultrafiltration as the only measure to control hypertension.
If hypertension continues to be a problem despite the use of antihypertensives, especially in the presence of extracellular volume expansion, intensification of ultrafiltration may be acceptable. In the postpartum period, the more liberal use of ultrafiltration is useful in controlling blood pressure, allowing for the decrease in the dose or discontinuation of the medications. It has been speculated that aggressive ultrafiltration in the post-partum period may affect milk production negatively, although this has not been well documented.
The level of dialysate calcium to sufficiently prevent a significant rise in PTH is usually higher than 3.5 mEq/L or 1.75 mmol/L. Often, the amount of intradialytic phosphorus needs to be increased to as high as 200 ml of Fleet® enema per dialysate jug. The amount is adjusted to ensure that both the pre- and post- dialysis serum phosphate are maintained normal.
The ideal level of hemoglobin is unknown. Intravenous iron is administered as needed to maintain a transferrin saturation of 0.25 or higher. This usually requires an increased dose of intravenous iron.
Pregnancy is normally associated with respiratory alkalosis, which in turn is associated with lower serum bicarbonate as part of the kidney compensation. Some clinicians suggest decreasing the dialysate concentration of bicarbonate during pregnancy to achieve a similar effect. The level can be adjusted to maintain a predialysis serum bicarbonate at 20-22 mEq/L. No specific data exist to support the notion. Several pregnancies were successful without this adjustment.
Other effects of Frequent HD as described in the FHN trial
Frequent hemodialysis did not improve executive function or global cognition in the FHN trial.
Frequent in-center hemodialysis compared with conventional in-center hemodialysis improved self-reported physical health and functioning but had no significant effect on objective physical performance. There were no significant effects of frequent nocturnal hemodialysis on the same physical metrics.
The direct cost of more frequent dialysis is higher than CHD. The financial impact of intensive HD depends on the stakeholder's perspective. Some significant stakeholders include the dialysis providers, payers for dialysis, hospitalization, medication costs), patients, and society at large. Home dialysis includes higher capital costs but lower labor cost. The most expensive intensive hemodialysis modality is in-center SDHD, where the cost of both consumables and labor increase.
Ultimately, the reimbursement structure of the specific jurisdiction dictates the financial incentives or disincentives for the adoption of home daily intensive dialysis methods. Several observational studies in Canada, Australia, and the US suggest that the overall cost of patient care on home SDHD or daily NHD is lower than the cost of CHD, if the calculation includes hospitalization and medication costs. A cost utility study also found that the cost of QALY (Quality Adjusted Life Years) was lower on NHD as compared to CHD.
The reimbursement structure and rates in the US have been unfavorable for the use of daily home hemodialysis. This may have changed somewhat recently with the adoption of the "bundling" of the reimbursed items to include intravenous medications such as ESAs and vitamin D analogues, the use of which may be lower on intensive HD. There is no RCT comparing the cost of intensive to conventional dialysis. In-center intermittent NHD may be financially attractive depending on the intensity of labor utilization.
Current utilization
There are no accurate data on the utilization of intensive HD. Data from the International Quotidian Dialysis Registry suggest that the distribution of the intensive HD regimens differs in the different jurisdictions. The most frequent modality in Australia/New Zealand is every other day NHD at home, while in Canada daily NHD and in the US in-center NHD is the most common modality. The utilization of SDHD is increasing in the US, using mainly the NxStage dialysis system.
Patient survival
There are no RCT-derived data regarding patient survival on intensive HD. The complexity and the cost prohibit the likelihood that the study will ever be done.
Observational studies have described patient survival on the different schedules. Selection biases include younger age for the home HD patients (by about 10 years) and lower comorbidities.
Most of these studies, irrespective of intensive HD modality, have reported patient survival rates of about 80% over 5 years. A retrospective matched cohort study found similar survival rates with nocturnal hemodialysis in Canada and deceased donor transplantation (US data). In another study, deceased donor transplantation patient survival rates were higher than on nocturnal hemodialysis when only Canadian data was used.
Although patient mortality rates were not the primary end-points of the FHN trial, the 12-month frequent in-center hemodialysis significantly reduced the long-term mortality over a median of 3.6 years. Conversely patients assigned to nocturnal hemodialysis in the FHN trial had a higher mortality rate especially during the year after the completion of the trial; the low number of patients recruited and the surprisingly low mortality rate in the control group (0.03 deaths/patient year) make these results difficult to interpret.
Outcomes of Daily hemodialysis versus other modalities
In several studies based on institutional databases from Australia/New Zealand and North America, frequent and home hemodialysis had better patient survival rates, fewer hospital admissions and fewer conversions to in-center hemodialysis than peritoneal dialysis.
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- Does this patient have kidney disease that would benefit from daily and nocturnal dialysis?
- How should patients with kidney disease undergoing daily and nocturnal dialysis be managed?
- Instructions for adjustment of dialysate calcium
- Instructions for adjustment of dialysate phosphorus
- Clinical pearls on phosphate control
- Dialysis machines
- The NxStage system
- Desirable attributes of a home dialysis machine
- Water treatment
- Water treatment for the NxStage machine
- Electricity and drainage
- Electricity
- Water supply
- Drain
- Remote monitoring of the dialysis machine
- Solute removal
- Small molecules (urea)
- Phosphate
- Large molecules
- Urea kinetics in NHD
- Dialysis access
- What happens to patients with kidney disease undergoing daily and nocturnal dialysis?
- Clinical outcomes of intensive hemodialysis
- Blood pressure
- Regression of LVH
- Improvement in cardiac function and endothelial function
- Quality of life
- Residual kidney function
- Mineral metabolism
- Sleep
- Nutrition
- Erythropoiesis-stimulating agents and iron administration
- Effect on reproductive biology
- Other effects of Frequent HD as described in the FHN trial
- Cost
- Current utilization
- Patient survival
- Outcomes of Daily hemodialysis versus other modalities


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Therapeutic Grade Essential Oils
AromaHealth organically grows, distills and separates by glass therapeutic grade essential oils. They are pure and undiluted, fresh from the gardens. Essential oils heal on many levels: inhalation, touch, energy meridians , conscious and unconscious emotions and beliefs that trigger or drive responses. AromaHealth offers several applications and education to learn how to enjoy your body. Use our essential oils in skincare, therapeutic sprays, lotions, pain remedies, hair and bath products and blends diluted in a carrier oil base. Dilutions: in 1 ounce carrier oil, use 10 drops of essential oils; in 1 ounce of cream, dilute 5 drops of essential oils; for 4 ounces of unscented lotions, add 8-10 drops of essential oils. When in doubt about a choice, let your nose lead the way. And here's why!
Good Manufacturing Practices
Everyone is born with a unique scent they carry throughout life, like an apple or orange. The aroma is often not detected on a conscious level, unless closeness or intimacy is involved. I like to think of a baby's smell (when the diaper is clean!) . The scent makes me want to get closer to breathe in the baby's freshness. Essential oils and absolutes either harmonize with this scent, or help change it to its original aroma.A therapeutic essential oil is a highly concentrated, steam- distilled fragrant volatile oil produced by tiny glands located in various parts of aromatic plants. The oil evaporates quickly as the aromatic molecules by pass the blood brain barrier to effect the greatest healing. . Several pounds of plant material produce only one dram to one ounce of pure, undiluted oil. The material must be harvested when oil production is at a peak and distilled immediately. Only the purest essential oils and flower essences will unlock the healing capabilities of the flowers. AromaHealth essential oils are steam distilled and hand separated from the aromatic floral waters; we grow everything organically and distill on site. No hexane, chemical solvents, or synthetic additives are used to produce our essential oils, floral waters, and flower essences. We produce only the finest quality that Mother Nature has to offer. Essential oils are naturally anti-viral, anti- fungal, and antiseptic.
Absolutes are natural perfume quality extractions of fragrant flowers and resins that do not impart all of their aroma from steam distillation, such as jasmine. Absolutes are purified from semi- solid waxy flower material. Waxy particles do not dissolve completely and are filtered from the solution. This yields an absolute, the highest grade of natural perfume fragrance, which also have many beneficial properties. Absolutes hold their aroma in natural perfumes better than essential oils. Essential oils are more volatile and dissipate into the air quickly, or saturate into a carrier oil base.
Good Manufacturing Practices
Absolutes and essential oils may be combined in aromatic blends to complement each other and add an exquisite long lasting aroma to a blend. Absolutes also contain therapeutic properties of the original flower or resin.
Products sold by the dram, approximately 4 ml, or 200 drops. (1/6 oz.). Several absolutes are also available in 1/12 oz.
. See my class on You tube on Natural Fragrance, under Dr.Judy Griffin.
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subset: commoncrawl


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Billowy Sourdough Cinnamon Rolls with Cream Cheese Icing
I was inspired from Teresa at her Northwest Sourdough website to try her sourdough cinnamon rolls pictured there, but the closest actual written recipe I could find to that was her Festive Hawaiian Roll recipe. After studying a lot of other sweet dough recipes and brioche recipes, I decided to make a hybrid dough with what I thought were the best aspects of each, that would also use only sourdough starter as the leavening agent. The main differences from NWSD's recipe is my addition of eggs and buttermilk, plus I added 4 times the amount of butter, bringing the butter content up to 11%, which is still not as high as many sweet doughs and not nearly as high as brioche.
This recipe will make about 16-24 large and airy, but rich and tender Cinnamon Rolls. We don't like excess cinnamon flavor in our rolls and so use about half the amount of cinnamon usually called for in the filling of similar recipes. We are also not *fond* of white fondant glaze, so I made up this cream cheese/buttercream glaze to provide a more flavorful topping that complements the flavor of the rolls well. I also did not use any nuts in these, but they could also be added to the filling if desired.
Beware of these rolls: Due to the potato and buttermilk in the dough, these are by far the richest, most moist, tender, and flavorful cinnamon rolls we've ever had, the dough itself is fragrant with vanilla and butter, it almost does not need the filling or icing. The sourdough made these extraordinarily airy and puffy with no commercial yeast added. Because these are so rich, they will be reserved for special occasions or special visitors in our house, they are far too addictive to keep around otherwise. Because they are also so light and billowy - similar to a good sourdough waffle, they are not overly filling and heavy in your stomach.
The total preparation time is about 36 hours to allow for the long cool ferments. If you want to serve these rolls on a Sunday morning, you need to build the levain the preceding Friday evening.
Approx. 12 hours before making the final dough, build the levain as follows:
Levain Build:
grams Item
150 100% hydration sourdough starter, recently fed and ripened
340 Lukewarm water
340 AP flour
850 Total Wt.
Let this mixture sit at room temperature until doubled (usually overnight, if your starter is fast and the levain is active early, keep it in the frig. until ready to make dough). Meanwhile, make a small amount of mashed potato by boiling or microwaving (covered) 1 medium peeled & sliced potato in a little water until soft. Mash with fork and a little milk until smooth.
Final Dough:
grams Item
113 1 stick Unsalted butter, softened
225 3 large eggs
42 1 ½ TBSP Honey
24 2 TBSP Vanilla Extract
130 Mashed potato
195 ¾ c. Buttermilk or whole milk
850 Levain
700 AP flour
21 Salt
2300 Total Wt.
Once levain is ripe, make the final dough. First cream the softened (not melted) butter by hand or in mixer with paddle attachment, then beat in eggs, honey, vanilla, and mashed potato and continue mixing. Stop to scrape down sides of bowl with spatula as needed and continue to mix just until well-blended. Switch to dough hook and add buttermilk and levain until blended, then gradually add flour and salt and continue mixing with dough hook until well-blended. Scrape down sides of bowl with spatula, cover, and let rest 20 min. After rest, uncover and continue to mix with dough hook another 2-3 minutes (or by hand, fold in bowl with plastic bowl scraper for 3 min.). This will be a very soft, sticky dough, around 71% hydration if you count the liquid from eggs and milk, but not counting the butter.
Place the dough into a container sprayed with cooking oil, cover, and bulk ferment in a cool location (55-65F) until doubled, approx. 8-12 hours depending on temperature and how fast a riser your starter is. Every few hours, give the dough a stretch and fold, for a total of about 2 folds.
Meanwhile, make the filling as follows:
grams Item
170 1 ½ sticks Unsalted butter, softened
85 Cream or half&half
300 Dark brown sugar
180 Raisins
3 1 ½ tsp. Cinnamon
12 1 TBSP Vanilla extract
750 Total Wt.
For the filling, add all above ingredients to a medium sized saucepan and bring to a low boil over medium heat while stirring. As soon as the mixture boils, take off heat and chill to a spreadable consistency before using.
After dough has doubled, divide it into 2 pieces on a flour-dusted surface (it may be sticky even though the butter should be solid from the cool temps), then roll out each piece of dough into a rectangle shape about 10 x 16 inches across. Spread the filling across each rectangle of dough, leaving 1 inch clean where the outer seam edge of the roll will be and then taking the opposite edge, roll up the dough gently but firmly and seal the seam.
Slice each log into 8 or 12 rolls (depending on how big a rectangle you rolled out and how large you want the rolls to be) with serrated knife and place them just barely touching each other on baking parchment on sheet pan. Don't worry if log gets flattened as you slice each roll, you can straighten them out once placed on the sheet pan, and they should rise very high and straighten out when proofing. Spray tops of rolls lightly with cooking spray, cover with plastic wrap, and slowly proof rolls overnight or up to 12 hrs. in the refrigerator or cool place between 45 and 55F until the dough is about doubled and puffy looking. Bake right out of frig. at 400 degrees for about 25-35 minutes until light golden, or until the center of dough registers about 195-200F on instant-read thermometer. Do not let the rolls get very brown. Melt about 4 TBSP of butter in microwave and as soon as rolls are out of oven, brush them with the melted butter to keep crust soft before icing them.
Here are the rolls right out of oven and after being brushed with butter, they had a great amount of oven spring and rose tremendously during the bake:
While rolls are baking, make a glaze/icing as follows:
Cream Cheese Glaze:
grams Item
56 ½ (4 TBSP) stick Unsalted butter, softened
56 4 TBSP. Cream cheese
165 ¾ c. Confectioner's sugar
65 ¼ c. Milk, whole
2 ½ tsp. Vanilla extract
344 Total Wt.
Microwave the butter and cream cheese together until very soft but not melted. Whisk them together while adding the vanilla, powdered sugar, and enough milk to thin out the icing to a drip-able consistency.
Let the rolls mostly cool before glazing them with icing. Dip a wire whisk in the icing and drizzle across surface of each roll in crisscross pattern. Serve and enjoy.
(NOTE: I've not yet tried this, but it should also be possible to chill the un-sliced logs in frig overnight and slice just before baking, or freeze the logs for up to 1 month, take out the night before baking and defrost in frig. Next morning, remove from frig., slice, and let warm up at room temp about 1-2 hours before baking.)
It's a good thing we had a house full of guests this past weekend to help us put away not only the cinnamon rolls, but also these Vermont Sourdough boules, and cherry-sunflower-seed levains.


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I was assigned for 21 keywords at 1st jan 2013. All of the keywords have very high competition. Now today is 31 jan and its been 1 month. Not a single keywords is at the first page of google Now how much time will it take for the keywords to rank at first page of google ?? My boss is getting angry on me day by day (:
High competition keywords and you want a number one result? Well, it is very likely you will never get it with those keywords.
For sure there are sites using those keywords that have been in the business for a longer period of time and just for that reason will be hard to beat (although nothing is imposible)
first of all you need to decides the key phase of your keywords and than start again link buliding on that keywords. Maximum try to get backlinks from high pr sites. A well optimized blog can bring your keywords in top. example your keywords id "Magento developer" than first you have to decides the key phase like "hire magento developer india" ect. it will take time but surly gives you a result.
[FONT=verdana]Tell your boss that he is being unreasonable. There's no way you, or anyone else, can guarantee to get top ranking in Google for highly competitive keywords - and certainly not within a month. The best you can do is to keep plugging away, trying to improve your rankings a little at a time. Your boss should give you a more realistic set of goals.
You'd have to take each keyword individually. It's hard to comment without knowing how competitive they are. You can rank for any keyword with enough time and money. But to rank a new page or site for keywords in a month, the competition would have to be fairly low. What's the average PR of the top 10 sites for a keyword you're considering "competitive"? That's a good way to put a value on competitiveness.
I'm going to answer from my experience.
There are many keywords you want to position in Google, for that matter, Google will analyze some of your keywords before others. Everything will depend on the quality backlinks you have done and onpage optimization of your URL.
Anyway, Google recently on February 14 will the new update and we can see the new pagerank of our pages.
<snip>link deleted</snip>
You can submit your resignation letter to your boss because it is sure as hell impossible to rank the website on the first page of the SERPs for extremely competitive keywords within 1 month. Well, maybe possible if you utilize some black hat methods but surely very risky.
For these kinds of campaigns you would need at least 3 to 6 months to get to the top page.
It's hard to tell but you'll need at least 2 months to get any decent rankings for local searches 1,000. More local searches, more time to reach the first page.
Hi there,
I can understand because it is the common problem for all SEO analysts but you need to be clear from the starting. Before accepting the project you need to clarify every thing with your boss. Don't make any fake promises for the project. For high competitive keywords you need double hard work. I did not mean about double the links but you have to closely analyze your site and competitions.
Send the links of your site competitors to your boss. He or she will look at the sites and understand the difference.
Its depend upon your site quality and content.
For high competition keywords it will take long time nearly 6 to 8 months. Regular activities has to be carried out without any intervention. Definitely it will reach top position in google SERP.
And you know this how? We know nothing about the OP's site, or his competitors', only that his keywords have very high competition. Yes, he may reach the top position - after all, somebody has to have that slot - but you can't possible say that for certain, about this site or any other, for that matter.[/FONT]


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CANBERRA, Australia — Not one object has been recovered from the missing airliner that Malaysian officials are now convinced plunged into the southern Indian Ocean 17 days ago. Some of the pieces are likely 3,500 meters (11,500 feet) underwater. Others are bobbing in a fickle system of currents that one oceanographer compares to a pinball machine. And by now, they could easily be hundreds of kilometers (miles) away from each other.
The job of gathering this wreckage, and especially the black boxes that will help determine what happened to Malaysia Airlines Flight 370, is an unprecedented challenge. The crews who needed two years to find a black box from the Air France flight lost in the Atlantic in 2009 had much more information to go on.
"Even though that was the biggest and most complicated search for an aircraft in the ocean ever conducted, it was a relatively refined area compared with what we're talking about here," said U.S. underwater wreck hunter David Mearns, who advised both British and French investigators in the Air France case.
Malaysia said the latest search area had been narrowed to about 870,000 square kilometers (335,000 square miles, 470,000 square nautical miles), an area about as big as Texas and Oklahoma combined.
It was analysis of satellite data, rather than any confirmed wreckage, that led Malaysia to conclude Monday that Flight 370 plunged into the Indian Ocean 2,500 kilometers (1,550 miles) southwest of the Australian west coast city of Perth, and that all 239 people aboard died. Satellites and planes have seen objects in the water, large and small, but nothing has been retrieved or positively identified as coming from the Boeing 777-200.
Geoff Dell, discipline leader of accident investigation at Central Queensland University, said Tuesday that if the black boxes are found, it would be the most difficult search for a lost plane ever to succeed.
"We're not searching for a needle in a haystack," said Air Marshal Mark Binskin, Australia's deputy defense chief. "We're still trying to define where the haystack is."
Dell said there's an urgent need to find any wreckage from the plane. Even one piece would allow oceanographers to plot where it might have drifted from. That information, combined with the vague course of the plane calculated by British satellite company Inmarsat, could greatly refine the search area for pieces that have sunk.
"You've got a rough idea of the flight path from this satellite data. Using your best guesses, you've got to backtrack from where you've fished the pieces out of the water, based on current and wind," Dell said. "You're looking for those two paths to intersect and that would be your starting point, but there'd be many, many variables, estimations and tolerances in both of those paths."
The estimated paths of the flight and the current would produce "an X-marks-the-spot where we start looking, but it could be a couple of hundred miles off," he said.
The job gets harder every day the current carries wreckage away, said Erik van Sebille, an oceanographer at the University of New South Wales in Sydney. He said the swirling and unpredictable nature of currents can spread items that begin in the same place hundreds of kilometers (miles) apart within weeks.
"It's like one giant pinball machine out there," he said.
Weather is further complicating the task. The search was suspended for 24 hours Tuesday due to rough seas.
Binskin, the Australian deputy defense chief, said search planes had dropped electronic buoys near potential debris fields that have been seen in recent days, in hopes of keeping track of them.
Australian Defense Minister David Johnston said, "The turning point for us, I think, will be when we pull some piece of debris from the surface of the ocean and positively identify it as being part of the aircraft."
The search involves ships and planes from the United States, China, Japan, Australia, New Zealand and South Korea.
Malaysia said the U.S. Navy will deliver a black box pinger locator to Perth on Wednesday. The Australian warship that will tow the locator is due to arrive in the search area on April 5. By then, there may be little time left.
By law, the boxes must be able to send those signals for at least 30 days following a crash. But experts say they can continue making noise for another 15 days or so beyond that, depending on the strength of the black box battery.
Hans Weber, the president and owner of TECOP International, a San Diego-based aviation consulting firm, said that if the black boxes are submerged, the effectiveness of the pinging they emit can be affected by variations in water temperature.
He said the ocean can form layers of water that are different temperatures, and that sometimes the pinging can effectively be reflected back by a different layer of water. He said the pinging works best in water that has a uniform temperature.
Dell said if the black boxes were several kilometers (miles) deep, the ships might need to be almost directly over them before the signal could detect them.
If found in deep water, Dell expected that unmanned submarines would be needed to retrieve them. That's how the black box from Air France Flight 447 was retrieved in May 2011, almost two years after the Airbus A330 crashed with the loss of 228 lives.
Mearns, the wreck hunter, said this week that Malaysian plane search is far more complex "because with Air France they knew the flight plan of the plane, the track of the plane, the last known position." The last 280 seconds of the plane's path were unclear, he said, compared to several hours for Flight 370.
And it did not take 17 days to find wreckage from Flight 447. Within five days, more than 100 pieces of debris were found.
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text:
Adult Orthodontics
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text:
Americans waste more than 40 percent of the food we produce for consumption. That comes at an annual cost of more than $100 billion. At the same time, food prices and the number of Americans without enough to eat continues to rise.
Fusing my journalistic research on the topic with the work of countless others, this site examines how we squander so much food. Part blog, part call to action, Wasted Food aims to shed light on the problem of, you guessed it, wasted food.
I've been researching this topic since 2005, when two experiences made me aware of just how much food is wasted. Volunteering at D.C. Central Kitchen, a homeless shelter that rescues unused food from restaurants and supermarkets illuminated the excess in those areas. Gleaning, or gathering crops that would otherwise be left in the field and distributing them to the hungry, illustrated the agricultural abundance that is often plowed under.
When you're looking for it, you see food waste everywhere–at restaurants, in large portions and even in your own refrigerator. If more and more people recognize their own food waste, we can take a bite out of this problem.
Hope you're hungry for change.


text:
Read the full story here Web Link posted Wednesday, June 12, 2013, 9:54 AM
Town Square
Suspect at large in Palo Alto armed robbery
Original post made on Jun 12, 2013
Read the full story here Web Link posted Wednesday, June 12, 2013, 9:54 AM
Comments (18)
a resident of Another Palo Alto neighborhood
on Jun 12, 2013 at 10:02 am
So pleased the clerk is OK.
So pleased that the 7 - 11 has cctv and hope that this helps to catch the guy.
Thanks for getting the news out so quicly.
a resident of Midtown
on Jun 12, 2013 at 10:13 am
The photos in the article obviously came from a store surveillance camera. Hopefully this perp's friends or family will recognize the clothing or body shape. There is no shame in turning in a friend or family member who commits serious crimes like this! Armed robbery is just one flinch away from murder.
a resident of Midtown
on Jun 12, 2013 at 11:07 am
This store has been robbed so many times. Poor clerks, it must be very scary. The image of the surveillance camara is so poor. I a am wonder why they do not buy better camera. Where we can see the image of the thief clearly.
a resident of Charleston Gardens
on Jun 12, 2013 at 11:08 am
That poor clerk. I hope the scumbag robber gets caught. This isn't about money, it's about being traumatized.
a resident of East Palo Alto
on Jun 12, 2013 at 11:20 am
3rd time in 2 yrs. You would think that PAPD would be on to this by now.
There can't be that many other places for them to be. Especially considering the number of times it has been robbed.
They will wait until someone gets hurt, unfortunately.
a resident of Another Palo Alto neighborhood
on Jun 12, 2013 at 11:34 am
Perp made quite the fashion statement.
a resident of Palo Verde
on Jun 12, 2013 at 11:42 am
At this rate you'd probably have to watch the place for 10000 to 20000 hours continuously before seeing it robbed again. What do you think he got, 45 bucks and a candy bar?
a resident of Midtown
on Jun 12, 2013 at 12:45 pm
[Post removed by Palo Alto Online staff.]
a resident of Meadow Park
on Jun 12, 2013 at 1:34 pm
Yet another hood whom is to yellow to show face,hidden behind a ski-mask and requires a pistol to rob a store of monies.Hope the same reads what I have said because you are no man, but call yourself "A yellow moronic hood" Hopefully he or it shall be apprehended soon and thus pay the price.
a resident of Fairmeadow
on Jun 12, 2013 at 4:49 pm
It's a shame that the combined owners of this shopping area don't get together and purchase, or fund, some sort of outdoor surveillance equipment which could provide more information that we see in this picture. Given the right equipment, it might be possible to get the plate numbers of cars on Middlefield, and Colorado.
a resident of East Palo Alto
on Jun 12, 2013 at 4:59 pm
Exactly, Musical! Especially on a weekday, when the pickins are slimmer.
a resident of Midtown
on Jun 12, 2013 at 11:29 pm
To the Palo Alto Online staff
Would like to know why you removed a comment by Nayeli 10 hrs ago.
Nayeli regularly provides insightful and more interesting content than the Palo Alto Online writers. Perhaps not as politically correct, but definitely more intelligent.
a resident of Crescent Park
on Jun 13, 2013 at 8:02 am
It seems like this 7-11 gets robbed at least once a year.
I'm glad the clerk is OK.
That security footage is pathetic.
What is it going to take, someone getting shot, for 7-11 to do something about their poor security?
I don't think I've ever heard of the 7-11 in East Palo Alto getting robbed, why is the Midtown 7-11 such a target? The EPA 7-11 almost always has police in the parking lot at night.
Please catch this guy and make an example of him.
a resident of Palo Verde
on Jun 13, 2013 at 12:39 pm
precisely the problem. police arrest people to ''make an example'' without evidence of any crime, just ask joe ciampi. targeted because of image rather than facts. calling someone heroin addict . people know who is really an addict .no, nobody is a ciampi supporter or even agrees with him, but many are targeted an cops want to ''make an example''. a crime is a crime ,but not ''an example''. a crime must be based on facts. but as it was quoted in the daily journal, ''you cant win an argument against an ignorant person''. no use arguing here , marijuana isnt dangerous like diesel pollution, but ignorant people will say otherwise. guess smart people dont post here.
a resident of Midtown
on Jun 13, 2013 at 6:04 pm
[Portion removed by Palo Alto Online staff.]
I hope that they find this thug. I hope that he is removed from the streets and prevented from ever terrorizing anyone.
a resident of Midtown
on Jun 14, 2013 at 6:33 am
Yes, I agree with most comments on why this store isn't part of a routine check with PAPD. One a year our 7-11 is robbed. But hopefully they have a safe drop that can not be opened by anyone except Armored. But then again, this also could come to a clerks doom by not having money to satisfy the prepatratior. It is also very lucky that none of our Neighborhood kids walked in on this robbery. So, many are out for the summer and I can usually hear many teenagers walking up and down Colorado Ave, to get their late night snacks. Ten to one says this a repeat offender who knows or shops at this location. He knows this area is not routinely patrolled, Let's face facts, How Often do you see patrol cars in this area. Most homes and businesses are targets for crime around here because this is not a high crime area and unfortunately this is the south side of Palo Alto, receives almost next to no patrolling. A few months ago, I had a least three to four so called volunteers or non-profit organizations looking for donations... No I believe they were here to check out to see who was home and who wasn't. Lock all your doors and garage doors, keep your blinds closed and curtains pulled when not home. Lock your cars at night and if your going out of town, You don't need to tell everyone your going out of town except a reliable neighbor so they can keep an eye on your home for you. Have your mail stopped while you are gone, over stocked mail or newspapers are clues that you are not home. Be sure to share safety tips with other friends and especially any of your elderly neighbors. Let's try and keep it safe. Sorry 7-11 glad to hear no one was injured in this dangerous robbery!!
a resident of South of Midtown
on Jun 14, 2013 at 12:49 pm
go out at night. there is cop trucks all over south palo. they drive suv type trucks. cops are everywhere you just dont notice them.
a resident of Palo Verde
on Jun 14, 2013 at 5:22 pm
"Most homes and businesses are targets for crime around here because this is not a high crime area"
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Public transport
Public transport (or public transportation) is trains, trams, buses, and other passenger transport available for use by the public. It is also known as mass transportation, or mass transit, and applies particularly to most forms of transportation which can move large numbers of people at once. Public transport systems are often government-owned and financed, but not always.
Range of the term
There is no universally-accepted definition of the term. The main forms of public transport are rail-based services (such as trains and trams) and buses, but in some places ferries are also significant. Taxis are sometimes included, especially where they provide shared-ride services. Services by air and sea, other than ferries, are not normally included in the term. Neither are long-distant rail and bus services often included. The term tends to be used of services within a city or town, or between nearby cities and towns.
Types of Public Transport
The following are all types of public transport:
Public transport providers
Public transport may be provided by privately owned operators, governments, or a combination of the two, a situation often referred to as "public-private partnerships."
The complexities of ownership and operation can be illustrated with the example of Melbourne, Australia, where public transport service was originally provided by private companies, but these were later taken over by the state government, usually when the private operators got into financial difficulties. The government also greatly expanded the rail system. Although the original tram operators were private companies, the tram network was greatly expanded by municipal councils providing services, but the state government subsequently took over all these operators. Many bus services were provided by private companies, but under government regulation, although the state government also owned and operated some bus services itself. In the late 1990s, the government contracted with private operators to operate the railway and tram systems, although these remained under government ownership and oversight.
Note that the word "public" in public transport does not refer to government ownership of the service. Public transport services may be provided entirely by the private sector, whilst private transport usually operates on roads provided by the public sector and paid for by taxpayers.
Public versus private transport
Public transport offers a number of advantages over private transport (mainly cars), but private transport also has some advantages over public transport. Whether one form of transport is better than another form frequently depends on circumstances specific to the location and the user.
Private transport mainly comprises cars (US: automobiles), but can include motorcycles, bicycles and walking
Public transport provides transport to almost anybody, whereas private transport is limited to people able and licensed to drive or able to ride a bicycle or walk. Therefore, people too young to drive, people with disabilities that prevent or make it difficult to use private transport, including many older people, are often not able to use private transport, except by having someone else drive them. Many people dislike this lack of freedom to get around.
The ability of public transport to carry people with disabilities, particularly people confined to wheelchairs, varies, but many governments now require that public transport be able to carry such people. This can be helped by low-floor buses and trams, "kneeling" buses (that lower themselves to the ground to allow people to board), floor-height platforms, lifts at railway stations, and the like.
Freedom of travel
Public transport cannot achieve the degree of freedom that private transport allows to travel wherever and whenever a person wishes to. This is because public transport almost always operates on fixed routes and fixed schedules, and operation is often limited to specific times of the day and days of the week.
However, in places where public transport networks provide a good geographical coverage and operate frequent services for most or all hours of the day, seven days per week, this limitation of public transport can be minimised.
Of course, many people are not restricted to one or the other, but can use public transport where and when it is available and private transport for other journeys.
Relative costs vary enormously from system to system and circumstance to circumstance.
Walking and cycling are almost always cheaper than using public transport.
Travel by car can be cheaper than public transport when several people are travelling together, or where public transport charges by distance but doesn't provide a direct route or requires more than one fare to complete a journey. Public transport can be cheaper than travel by car when one fare can be used across several modes or for several journeys, when petrol (US: gasoline) is expensive, when other charges, such as parking fees or congestion charges are taken into account, or when the fixed costs of running a car, such as maintenance, registration, insurance, and loan repayments are included, particularly if the car can be disposed of and public transport used exclusively.
Travel by car or motorcycle, and sometimes bicycle, is often faster than a public transport service which makes many stops and might follow a circuitous route. However, where public transport operates on its own right of way (easement) and therefore avoids traffic congestion, or where it operates express (non-stop or limited-stop) services, it can often be faster than travel by car in peak periods.
Over longer distances, railways sometimes operate at speeds higher than any other land-based transport, with high-speed trains in various countries regularly operating at speeds over 300 kph (180 mph).
Travel environment
Travel by car allows one some freedom and benefits not available with public transport, such as not having to mix with, or crowd in with, many other people, to listen to music or audio without disturbing others, and so on. Travel by public transport imposes some social restrictions on people to be courteous and not disturb others who may not wish to be disturbed.
Travel by car allows one to travel in relative comfort, whereas seating in public transport may be uncomfortable or unavailable due to the number of people travelling exceeding the number of seats provided.
On the other hand, private transport tends to encourage or at least facilitate people isolating themselves from society, whereas public transport encourages people to be part of society. And public transport often allows one some freedom to stretch and move around, usually not possible with car travel except by stopping for this purpose and therefore extending the journey time. Travel on public transport allows one to watch videos, use a computer, read a newspaper, sleep, and other activities not possible whilst driving a vehicle.
Use of resources
Assuming that public transport is sufficiently-well used, public transport uses far fewer resources than car transport per person carried per kilometre or mile. This includes energy use (whether petroleum-based or electricity), land use for transport corridors, and land use for parking of vehicles.
To provide for people driving cars to work, sporting venues, etc., significant tracts of land have to be set aside for parking adjacent to the travel destination, whereas much less land or even no land needs to be set aside for public transport (which requires much less space per person carried, or can be run to a parking area remote from the travel destination).
Because public transport uses less fuel than cars, pollution is reduced, or even (potentially) eliminated if the public transport is run on electricity generated remote from the traffic or from environmentally-friendly sources, such as wind, hydro, and solar power.
Environmentalists promote public transport on the grounds that it is better for the environment, but it is also good stewardship of God's creation.