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JKDA 2023; 6(2): 47-51

Published online November 25, 2023

https://doi.org/10.56774/jkda23013

© Korean Society of Dialysis Access

Far-infrared Therapy for Hemodialysis Patients

Minsung Lee1, Soo Jeong Choi2

1Division of Nephrology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
2Division of Nephrology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea

Correspondence to : Soo Jeong Choi
Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Jung-dong, Wonmi-Gu, Bucheon 14584, Korea
Tel: 82-32-621-5169, Fax: 82-32-621-5016, E-mail: crystal@schmc.ac.kr

Received: September 26, 2023; Revised: October 21, 2023; Accepted: October 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Although the arteriovenous fistula is considered the best access due to low complications, it faces challenges such as poor maturation rates and patency issues. The present paper describes the current status of far-infrared therapy as a treatment modality to enhance AVF maturation and access survival. The mechanism underlying FIR therapy involves vasodilatory, angiogenesis, and the induction of vasodilation and anti-inflammatory factors. Thermal effect of FIR therapy involve upregulation of endothelial nitric oxide synthase, while non-thermal effects include reduced oxidative stress and improved endothelial function. In conclusion, FIR therapy presents potential benefits for improving vascular access flow and survival.

Keywords Arteriovenous fistula, Far-infrared therapy, Dialysis

A hemodialysis (HD) access, also known as a vascular access, is a conduit for accessing the bloodstream during hemodialysis treatment. This vascular access enables blood to flow through flexible tubes to the dialysis machine, where it undergoes dialysis process by passing through a specialized filter known as a dialyzer. A well-functioning vascular access is an important and essential factor for achieving adequate dialysis in hemodialysis patients. Arteriovenous Fistula (AVF) has been considered as the best access due to low complication (infection and thrombosis). But, AVF should overcome limitations of poor maturation rate (20-50%) and patency. Half of AVF needs an intervention within 1 year for stenosis [1]. High age, female sex, comorbidity, arterial stiffness, anatomical location (primarily radio-cephalic), small vein diameter and surgeon experience are all risk factors of access short survival [1-4]. Therefore, recent KDOQI guidelines recommend individual approach for access formation [5]. Many researchers have tried to improve vascular access survival with medications and other techniques. The surveillance and preemptive PTA were disappointed in this point. Although systemic management for such as dipyridamole+aspirin and fish oil have been successful, systemic levels of such agents may expose the patients to significant adverse effects [6,7]. Therefore, local treatment modalities began to be developed, and Far-infrared (FIR) therapy is one of them. FIR therapy is a new treatment modality for AVF maturation and access survival [8-11].

The present paper describes the current status of FIR therapy in HD patients.

Infrared radiation is an invisible electromagnetic energy, and the range with wavelengths between 5.6-1,000 µm is referred to as FIR. Infrared radiation likely transfers various energy forms into subcutaneous tissue level without causing stimulation or excessive heating. FIR radiation produces both thermal and non-thermal effects [12]. FIR therapy transfers energy in the surrounding skin [13]. FIR therapy improves skin blood flow and angiogenesis [14]. FIR therapy also improves endothelial function and reduces the frequency of some cardiovascular diseases [15-17]. The first FIR therapy was ‘Waon’ sauna therapy in Japanese patients with chronic heart failure [18,19]. This FIR sauna irradiates the entire body at 60°C for 15 minutes, followed by a further 30 minutes covered in blankets to cause an increase in core body temperature of around 1°C [20,21]. Localized FIR therapy is the other form, which typically consists of a device with ceramic plates [22]. This local FIR therapy improved hemodynamic function in chronic heart failure [22]. This thermal effect leads to vasodilation and angiogenesis for wound healing and peripheral ischemia [12]. And, FIR radiation inducts vasodilation and anti-inflammatory factor such as nitric oxide and heme oxygenase, which inhibits vascular endothelial inflammation [16,23]. Heme oxygenase-1 (HO-1) is one of the genetic factor in cardiovascular diseases and AVF patency, and FIR therapy can aid in the patency and maturation of AVF through non-thermal reactions mediated by HO-1 [24].

The previous FIR protocol in HD patients was similar to the protocol used by Lin et al. [10] in their research on the effects of FIR on AVF maturation [25,26]. FIR therapy was administered for 40 min during each HD session. Specialized FIR emitters (WS TY-101N; WS Far Infrared Medical Technology Co., Ltd., Taipei, Taiwan) were used for FIR therapy. Electrified ceramic plates were positioned approximately 25 cm above the skin surface at the needling site. The irradiating power density was about 10 and 20 μW/cm2 when the radiator was set at a distance of 30 and 20 cm above the skin surface, respectively. Radiation therapy was continued every HD session. Chang et al. [27] introduced PD protocol with FIR therapy taken at least 4 times a week. FIR therapy was centered on the navel region, i.e., the entire abdominal cavity, from the lower edge of the sternum to the groin. The recommended safe distance that still allows reaching the skin was 25 cm. Before going to bed, the PD patients were irradiated for 40 min after the dialysate input.

FIR therapy in HD patients was studied for vascular access flow, vessel diameter, primary patency, cumulative patency (or occlusion) [28].

Lin et al. [10] showed FIR therapy improves access flow and maturation of newly created AVFs. FIR therapy for 1 year improved vascular access flow and a better unassisted patency of AVF [8]. But, Choi et al. [26] didn’t find an improved patency in AVF after 1 year. Lai et al. [11] reported that FIR therapy after PTA enhanced unassisted patency at 1 year in AVG, while it had no effect in AVF. Io et al. [29] revealed that FIR therapy increased intervention interval, expended fistula diameter, and improved intimal thickening in 13 patients underwent previous percutaneous transluminal angioplasty.

Bashar et al. [30] showed a meta-analysis on 4 RCTs, examining the primary (unassisted) and secondary patency rates of AVFs with FIR therapy in 2014. Patients received FIR therapy showed a significant increase in unassisted patency compared to the control group. Additionally, for secondary patency, patients received FIR therapy also demonstrated a significant difference in patency rates [30]. Wan et al. [28] conducted a meta-analysis of 21 RCTs investigating the protective effect of FIR therapy on AVFs in 2017. They found a significant increase in blood flow, diameter, and primary AVF patency in the group of patients receiving FIR therapy.

Although definite mechanism of FIR therapy is unknown, these results show thermal and non-thermal effects on hemodialysis access. Upregulation of endothelial nitric oxide synthase is considered to be a thermal effect which improves access blood flow [16,31,32]. In addition, this perivascular approach is appealing given without (a) stress of the adventitial and medial layers and (b) denudation of the endothelial layer [33]. Decreases in oxidative stress, suppression of inflammation, and improved endothelial function [6,16,23,32,34] have been suggested to be non-thermal effects.

FAITH on fistula (a randomized, controlled) trial has been explored to reveal the effect of FIR on AVF maturation and on number of AVFs without intervention still functioning after 1 year [35]. Vascular cell adhesion molecule (VCAM) is a well-known biomarker of endothelial dysfunction, and intracellular adhesion molecules (ICAM) is a marker for inflammation in atherosclerosis. Recent partial report of that study shows a single FIR therapy attenuated the decrease in soluble VCAM and ICAM in AVF while there was no significant change of inflammation and vaso-regulatory factors [25]. Therefore, the hypothesis that single FIR leads to an acute release of vascular protective dilatory factors and reduce inflammatory contractile factors is unproven. Other objectives of FAITH on fistula trial will reveal the long-term effect of AVF maturation on newly placed AVFs and overall patency in prevalent and incident AVFs [35].

There was a prospective randomized controlled trial on the effects of FIR therapy on AVF maturation and patency in patients with diabetic end-stage renal disease conducted by Chen et al. [36]. In addition, they also studied the effect on serum Asymmetric dimethylarginine (ADMA) level, an endogenous inhibitor of nitric oxide synthase, which plays a crucial role in the pathophysiology of AVF dysfunction. The study showed a decrease in ADMA levels and increase in AVF blood flow, maturation rate, and 1-year patency rate [36].

FIR has been used in HD patients for pain reduction and ischemia improvement. Choi et al. [26] reported FIR therapy decreased the needling pain which is similar with that of buttonhole technique. Chen et al. [36] revealed the 6-month FIR therapy improves ankle brachial index in hemodialysis patients with peripheral artery disease. They suggested FIR therapy is a promising and non-invasive therapeutic modality to treat vascular access related hand ischemia [36]. Taiwan researchers adopted FIR therapy in peritoneal dialysis. A 3- month FIR therapy treated encapsulating peritoneal sclerosis in a 45-year old men [37].

Chang et al. [27] intended 6-month FIR therapy in patients on peritoneal dialysis to improve peritoneal permeability and inflammatory response. But, their results didn’t show significant change of abdominal vessel, peritoneal Kt/V and inflammatory cytokines.

Choi et al. [26] evaluated the safety of FIR therapy. Thirty-two percent of participants discontinued FIR therapy than in other reports (3.4-12.5%) [8,9]. While others [8,11] reported no complications associated with FIR therapy, side effects such as an itching sensation and delayed hemostasis were reported. The FAITH trial monitors adverse events every three months, with the final data collection scheduled for April 2024 [35].

While FIR therapy improves vascular access flow with thermal effect, FIR therapy shows improvement of maturation and decrease of intervention risk in AVF. The non-thermal mechanism remains to be explored in clinical settings. More large and multicenter studies are needed to evaluate the effect of FIR therapy on access survival in hemodialysis patients.

  1. Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, et al. Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis. Am J Kidney Dis 2014; 63(3): 464-78.
    Pubmed CrossRef
  2. Bashar K, Conlon PJ, Kheirelseid EA, Aherne T, Walsh SR, Leahy A. Arteriovenous fistula in dialysis patients: Factors implicated in early and late AVF maturation failure. Surgeon 2016; 14(5): 294-300.
    Pubmed CrossRef
  3. Lauvao LS, Ihnat DM, Goshima KR, Chavez L, Gruessner AC, Mills JL Sr. Vein diameter is the major predictor of fistula maturation. J Vasc Surg 2009; 49(6): 1499-504.
    Pubmed CrossRef
  4. Lok CE, Sontrop JM, Tomlinson G, Rajan D, Cattral M, Oreopoulos G, et al. Cumulative patency of contemporary fistulas versus grafts (2000-2010). Clin J Am Soc Nephrol 2013; 8(5): 810-8.
    Pubmed KoreaMed CrossRef
  5. Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75(4 Suppl 2): S1-S164.
    Pubmed CrossRef
  6. Dixon BS, Beck GJ, Vazquez MA, Greenberg A, Delmez JA, Allon M, et al. Effect of dipyridamole plus aspirin on hemodialysis graft patency. The New England journal of medicine 2009; 360(21): 2191-201.
    Pubmed KoreaMed CrossRef
  7. Lok CE, Moist L, Hemmelgarn BR, Tonelli M, Vazquez MA, Dorval M, et al. Effect of fish oil supplementation on graft patency and cardiovascular events among patients with new synthetic arteriovenous hemodialysis grafts: a randomized controlled trial. Jama 2012; 307(17): 1809-16.
    Pubmed KoreaMed CrossRef
  8. Lin CC, Chang CF, Lai MY, Chen TW, Lee PC, Yang WC. Far-infrared therapy: a novel treatment to improve access blood flow and unassisted patency of arteriovenous fistula in hemodialysis patients. Journal of the American Society of Nephrology:. JASN 2007; 18(3): 985-92.
    Pubmed CrossRef
  9. Lin CC, Chung MY, Yang WC, Lin SJ, Lee PC. Length polymorphisms of heme oxygenase-1 determine the effect of far-infrared therapy on the function of arteriovenous fistula in hemodialysis patients: a novel physicogenomic study. Nephrology, dialysis, transplantation :. official publication of the European Dialysis and Transplant Association - European Renal Association 2013; 28(5): 1284-93.
    Pubmed CrossRef
  10. Lin CC, Yang WC, Chen MC, Liu WS, Yang CY, Lee PC. Effect of far infrared therapy on arteriovenous fistula maturation: an open-label randomized controlled trial. Am J Kidney Dis 2013; 62(2): 304-11.
    Pubmed CrossRef
  11. Lai CC, Fang HC, Mar GY, Liou JC, Tseng CJ, Liu CP. Post-angioplasty far infrared radiation therapy improves 1-year angioplasty-free hemodialysis access patency of recurrent obstructive lesions. Eur J Vasc Endovasc Surg 2013; 46(6): 726-32.
    Pubmed CrossRef
  12. Shui S, Wang X, Chiang JY, Zheng L. Far-infrared therapy for cardiovascular, autoimmune, and other chronic health problems: A systematic review. Exp Biol Med (Maywood) 2015; 240(10): 1257-65.
    Pubmed KoreaMed CrossRef
  13. Capon A, Mordon S. Can thermal lasers promote skin wound healing?. Am J Clin Dermatol 2003; 4(1): 1-12.
    Pubmed CrossRef
  14. Yu SY, Chiu JH, Yang SD, Hsu YC, Lui WY, Wu CW. Biological effect of far-infrared therapy on increasing skin microcirculation in rats. Photodermatol Photoimmunol Photomed 2006; 22(2): 78-86.
    Pubmed CrossRef
  15. Imamura M, Biro S, Kihara T, Yoshifuku S, Takasaki K, Otsuji Y, et al. Repeated thermal therapy improves impaired vascular endothelial function in patients with coronary risk factors. J Am Coll Cardiol 2001; 38(4): 1083-8.
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  16. Ikeda Y, Biro S, Kamogawa Y, Yoshifuku S, Eto H, Orihara K, et al. Repeated sauna therapy increases arterial endothelial nitric oxide synthase expression and nitric oxide production in cardiomyopathic hamsters. Circ J 2005; 69(6): 722-9.
    Pubmed CrossRef
  17. Kihara T, Biro S, Ikeda Y, Fukudome T, Shinsato T, Masuda A, et al. Effects of repeated sauna treatment on ventricular arrhythmias in patients with chronic heart failure. Circ J 2004; 68(12): 1146-51.
    Pubmed CrossRef
  18. Tei C, Horikiri Y, Park JC, Jeong JW, Chang KS, Tanaka N, et al. [Effects of hot water bath or sauna on patients with congestive heart failure: acute hemodynamic improvement by thermal vasodilation]. J Cardiol 1994; 24(3): 175-83.
  19. Tei C, Tanaka N. Comprehensive therapy for congestive heart failure: a novel approach incorporating thermal vasodilation. Intern Med 1996; 35(1): 67-9.
    Pubmed CrossRef
  20. Fujita S, Ikeda Y, Miyata M, Shinsato T, Kubozono T, Kuwahata S, et al. Effect of Waon therapy on oxidative stress in chronic heart failure. Circ J 2011; 75(2): 348-56.
    Pubmed CrossRef
  21. Sobajima M, Nozawa T, Fukui Y, Ihori H, Ohori T, Fujii N, et al. Waon therapy improves quality of life as well as cardiac function and exercise capacity in patients with chronic heart failure. Int Heart J 2015; 56(2): 203-8.
    Pubmed CrossRef
  22. Inoue S, Takemoto M, Chishaki A, Ide T, Nishizaka M, Miyazono M, et al. Leg heating using far infra-red radiation in patients with chronic heart failure acutely improves the hemodynamics, vascular endothelial function, and oxidative stress. Intern Med 2012; 51(17): 2263-70.
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  23. Lin CC, Liu XM, Peyton K, Wang H, Yang WC, Lin SJ, et al. Far infrared therapy inhibits vascular endothelial inflammation via the induction of heme oxygenase-1. Arteriosclerosis, thrombosis, and vascular biology 2008; 28(4): 739-45.
    Pubmed KoreaMed CrossRef
  24. Chen CF, Yang WC, Lin CC. An update of the effect of far infrared therapy on arteriovenous access in end-stage renal disease patients. J Vasc Access 2016; 17(4): 293-8.
    Pubmed CrossRef
  25. Lindhard K, Jensen BL, Pedersen BL, Meyer-Olesen C, Rix M, Hansen HP, et al. Far infrared treatment on the arteriovenous fistula induces changes in sVCAM and sICAM in patients on hemodialysis. Nephrology, dialysis, transplantation :. official publication of the European Dialysis and Transplant Association - European Renal Association 2023; 38(7): 1752-60.
    Pubmed CrossRef
  26. Choi SJ, Cho EH, Jo HM, Min C, Ji YS, Park MY, et al. Clinical utility of far-infrared therapy for improvement of vascular access blood flow and pain control in hemodialysis patients. Kidney Res Clin Pract 2016; 35(1): 35-41.
    Pubmed KoreaMed CrossRef
  27. Chang Y, Chang JT, Lee MY, Huang MZ, Chao YCC, Shih YL, et al. Does Far-Infrared Therapy Improve Peritoneal Function and Reduce Recurrent Peritonitis in Peritoneal Dialysis Patients?. J Clin Med 2022; 11(6): 1624.
    Pubmed KoreaMed CrossRef
  28. Wan Q, Yang S, Li L, Chu F. Effects of far infrared therapy on arteriovenous fistulas in hemodialysis patients: a meta-analysis. Ren Fail 2017; 39(1): 613-22.
    Pubmed KoreaMed CrossRef
  29. Io H, Nakata J, Aoyama R, Inoshita H, Nakano T, Ishizaka M, et al. Far-infrared therapy for secondary vascular access patency of hemodialysis patients. Renal Replace Ther 2019; 5(1): 31.
    CrossRef
  30. Bashar K, Healy D, Browne LD, Kheirelseid EA, Walsh MT, Clarke-Moloney M, et al. Role of far infra-red therapy in dialysis arterio-venous fistula maturation and survival: systematic review and meta-analysis. PLoS One 2014; 9(8): e104931.
    Pubmed KoreaMed CrossRef
  31. Akasaki Y, Miyata M, Eto H, Shirasawa T, Hamada N, Ikeda Y, et al. Repeated thermal therapy up-regulates endothelial nitric oxide synthase and augments angiogenesis in a mouse model of hindlimb ischemia. Circ J 2006; 70(4): 463-70.
    Pubmed CrossRef
  32. Park JH, Lee S, Cho DH, Park YM, Kang DH, Jo I. Far-infrared radiation acutely increases nitric oxide production by increasing Ca(2+) mobilization and Ca(2+)/calmodulin-dependent protein kinase II-mediated phosphorylation of endothelial nitric oxide synthase at serine 1179. Biochemical and biophysical research communications 2013; 436(4): 601-6.
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  33. Terry CM, Dember LM. Novel therapies for hemodialysis vascular access dysfunction: myth or reality?. Clin J Am Soc Nephrol 2013; 8(12): 2202-12.
    Pubmed KoreaMed CrossRef
  34. Masuda A, Miyata M, Kihara T, Minagoe S, Tei C. Repeated sauna therapy reduces urinary 8-epi-prostaglandin F(2alpha). Japanese heart journal 2004; 45(2): 297-303.
    Pubmed CrossRef
  35. Lindhard K, Rix M, Heaf JG, Hansen HP, Pedersen BL, Jensen BL, et al. Effect of far infrared therapy on arteriovenous fistula maturation, survival and stenosis in hemodialysis patients, a randomized, controlled clinical trial: the FAITH on fistula trial. BMC Nephrol 2021; 22(1): 283.
    Pubmed KoreaMed CrossRef
  36. Chen CF, Chen FA, Tan AC, Lee TL, Chan CH, Lin CC. Far-infrared therapy improves ankle brachial index in hemodialysis patients with peripheral artery disease. Heart Vessels 2019; 34(3): 435-41.
    Pubmed CrossRef
  37. Ou SM, Hu FH, Yang WC, Lin CC. Far-infrared therapy as a novel treatment for encapsulating peritoneal sclerosis. Am J Gastroenterol 2014; 109(12): 1957-9.
    Pubmed CrossRef

Article

Review Article

JKDA 2023; 6(2): 47-51

Published online November 25, 2023 https://doi.org/10.56774/jkda23013

Copyright © Korean Society of Dialysis Access.

Far-infrared Therapy for Hemodialysis Patients

Minsung Lee1, Soo Jeong Choi2

1Division of Nephrology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
2Division of Nephrology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea

Correspondence to:Soo Jeong Choi
Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Jung-dong, Wonmi-Gu, Bucheon 14584, Korea
Tel: 82-32-621-5169, Fax: 82-32-621-5016, E-mail: crystal@schmc.ac.kr

Received: September 26, 2023; Revised: October 21, 2023; Accepted: October 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Although the arteriovenous fistula is considered the best access due to low complications, it faces challenges such as poor maturation rates and patency issues. The present paper describes the current status of far-infrared therapy as a treatment modality to enhance AVF maturation and access survival. The mechanism underlying FIR therapy involves vasodilatory, angiogenesis, and the induction of vasodilation and anti-inflammatory factors. Thermal effect of FIR therapy involve upregulation of endothelial nitric oxide synthase, while non-thermal effects include reduced oxidative stress and improved endothelial function. In conclusion, FIR therapy presents potential benefits for improving vascular access flow and survival.

Keywords: Arteriovenous fistula, Far-infrared therapy, Dialysis

INTRODUCTION

A hemodialysis (HD) access, also known as a vascular access, is a conduit for accessing the bloodstream during hemodialysis treatment. This vascular access enables blood to flow through flexible tubes to the dialysis machine, where it undergoes dialysis process by passing through a specialized filter known as a dialyzer. A well-functioning vascular access is an important and essential factor for achieving adequate dialysis in hemodialysis patients. Arteriovenous Fistula (AVF) has been considered as the best access due to low complication (infection and thrombosis). But, AVF should overcome limitations of poor maturation rate (20-50%) and patency. Half of AVF needs an intervention within 1 year for stenosis [1]. High age, female sex, comorbidity, arterial stiffness, anatomical location (primarily radio-cephalic), small vein diameter and surgeon experience are all risk factors of access short survival [1-4]. Therefore, recent KDOQI guidelines recommend individual approach for access formation [5]. Many researchers have tried to improve vascular access survival with medications and other techniques. The surveillance and preemptive PTA were disappointed in this point. Although systemic management for such as dipyridamole+aspirin and fish oil have been successful, systemic levels of such agents may expose the patients to significant adverse effects [6,7]. Therefore, local treatment modalities began to be developed, and Far-infrared (FIR) therapy is one of them. FIR therapy is a new treatment modality for AVF maturation and access survival [8-11].

The present paper describes the current status of FIR therapy in HD patients.

FIR THERAPY

Infrared radiation is an invisible electromagnetic energy, and the range with wavelengths between 5.6-1,000 µm is referred to as FIR. Infrared radiation likely transfers various energy forms into subcutaneous tissue level without causing stimulation or excessive heating. FIR radiation produces both thermal and non-thermal effects [12]. FIR therapy transfers energy in the surrounding skin [13]. FIR therapy improves skin blood flow and angiogenesis [14]. FIR therapy also improves endothelial function and reduces the frequency of some cardiovascular diseases [15-17]. The first FIR therapy was ‘Waon’ sauna therapy in Japanese patients with chronic heart failure [18,19]. This FIR sauna irradiates the entire body at 60°C for 15 minutes, followed by a further 30 minutes covered in blankets to cause an increase in core body temperature of around 1°C [20,21]. Localized FIR therapy is the other form, which typically consists of a device with ceramic plates [22]. This local FIR therapy improved hemodynamic function in chronic heart failure [22]. This thermal effect leads to vasodilation and angiogenesis for wound healing and peripheral ischemia [12]. And, FIR radiation inducts vasodilation and anti-inflammatory factor such as nitric oxide and heme oxygenase, which inhibits vascular endothelial inflammation [16,23]. Heme oxygenase-1 (HO-1) is one of the genetic factor in cardiovascular diseases and AVF patency, and FIR therapy can aid in the patency and maturation of AVF through non-thermal reactions mediated by HO-1 [24].

FIR THERAPY PROTOCOL

The previous FIR protocol in HD patients was similar to the protocol used by Lin et al. [10] in their research on the effects of FIR on AVF maturation [25,26]. FIR therapy was administered for 40 min during each HD session. Specialized FIR emitters (WS TY-101N; WS Far Infrared Medical Technology Co., Ltd., Taipei, Taiwan) were used for FIR therapy. Electrified ceramic plates were positioned approximately 25 cm above the skin surface at the needling site. The irradiating power density was about 10 and 20 μW/cm2 when the radiator was set at a distance of 30 and 20 cm above the skin surface, respectively. Radiation therapy was continued every HD session. Chang et al. [27] introduced PD protocol with FIR therapy taken at least 4 times a week. FIR therapy was centered on the navel region, i.e., the entire abdominal cavity, from the lower edge of the sternum to the groin. The recommended safe distance that still allows reaching the skin was 25 cm. Before going to bed, the PD patients were irradiated for 40 min after the dialysate input.

FIR RADIATION FOR HEMODIALYSIS ACCESS

FIR therapy in HD patients was studied for vascular access flow, vessel diameter, primary patency, cumulative patency (or occlusion) [28].

Lin et al. [10] showed FIR therapy improves access flow and maturation of newly created AVFs. FIR therapy for 1 year improved vascular access flow and a better unassisted patency of AVF [8]. But, Choi et al. [26] didn’t find an improved patency in AVF after 1 year. Lai et al. [11] reported that FIR therapy after PTA enhanced unassisted patency at 1 year in AVG, while it had no effect in AVF. Io et al. [29] revealed that FIR therapy increased intervention interval, expended fistula diameter, and improved intimal thickening in 13 patients underwent previous percutaneous transluminal angioplasty.

Bashar et al. [30] showed a meta-analysis on 4 RCTs, examining the primary (unassisted) and secondary patency rates of AVFs with FIR therapy in 2014. Patients received FIR therapy showed a significant increase in unassisted patency compared to the control group. Additionally, for secondary patency, patients received FIR therapy also demonstrated a significant difference in patency rates [30]. Wan et al. [28] conducted a meta-analysis of 21 RCTs investigating the protective effect of FIR therapy on AVFs in 2017. They found a significant increase in blood flow, diameter, and primary AVF patency in the group of patients receiving FIR therapy.

Although definite mechanism of FIR therapy is unknown, these results show thermal and non-thermal effects on hemodialysis access. Upregulation of endothelial nitric oxide synthase is considered to be a thermal effect which improves access blood flow [16,31,32]. In addition, this perivascular approach is appealing given without (a) stress of the adventitial and medial layers and (b) denudation of the endothelial layer [33]. Decreases in oxidative stress, suppression of inflammation, and improved endothelial function [6,16,23,32,34] have been suggested to be non-thermal effects.

FAITH on fistula (a randomized, controlled) trial has been explored to reveal the effect of FIR on AVF maturation and on number of AVFs without intervention still functioning after 1 year [35]. Vascular cell adhesion molecule (VCAM) is a well-known biomarker of endothelial dysfunction, and intracellular adhesion molecules (ICAM) is a marker for inflammation in atherosclerosis. Recent partial report of that study shows a single FIR therapy attenuated the decrease in soluble VCAM and ICAM in AVF while there was no significant change of inflammation and vaso-regulatory factors [25]. Therefore, the hypothesis that single FIR leads to an acute release of vascular protective dilatory factors and reduce inflammatory contractile factors is unproven. Other objectives of FAITH on fistula trial will reveal the long-term effect of AVF maturation on newly placed AVFs and overall patency in prevalent and incident AVFs [35].

There was a prospective randomized controlled trial on the effects of FIR therapy on AVF maturation and patency in patients with diabetic end-stage renal disease conducted by Chen et al. [36]. In addition, they also studied the effect on serum Asymmetric dimethylarginine (ADMA) level, an endogenous inhibitor of nitric oxide synthase, which plays a crucial role in the pathophysiology of AVF dysfunction. The study showed a decrease in ADMA levels and increase in AVF blood flow, maturation rate, and 1-year patency rate [36].

FIR RADIATION FOR OTHER AIMS

FIR has been used in HD patients for pain reduction and ischemia improvement. Choi et al. [26] reported FIR therapy decreased the needling pain which is similar with that of buttonhole technique. Chen et al. [36] revealed the 6-month FIR therapy improves ankle brachial index in hemodialysis patients with peripheral artery disease. They suggested FIR therapy is a promising and non-invasive therapeutic modality to treat vascular access related hand ischemia [36]. Taiwan researchers adopted FIR therapy in peritoneal dialysis. A 3- month FIR therapy treated encapsulating peritoneal sclerosis in a 45-year old men [37].

Chang et al. [27] intended 6-month FIR therapy in patients on peritoneal dialysis to improve peritoneal permeability and inflammatory response. But, their results didn’t show significant change of abdominal vessel, peritoneal Kt/V and inflammatory cytokines.

SAFETY

Choi et al. [26] evaluated the safety of FIR therapy. Thirty-two percent of participants discontinued FIR therapy than in other reports (3.4-12.5%) [8,9]. While others [8,11] reported no complications associated with FIR therapy, side effects such as an itching sensation and delayed hemostasis were reported. The FAITH trial monitors adverse events every three months, with the final data collection scheduled for April 2024 [35].

CONCLUSION

While FIR therapy improves vascular access flow with thermal effect, FIR therapy shows improvement of maturation and decrease of intervention risk in AVF. The non-thermal mechanism remains to be explored in clinical settings. More large and multicenter studies are needed to evaluate the effect of FIR therapy on access survival in hemodialysis patients.

ACKNOWLEDGMENTS

This study was supported by the Soonchunhyang University Research Fund.

References

  1. Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, et al. Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis. Am J Kidney Dis 2014; 63(3): 464-78.
    Pubmed CrossRef
  2. Bashar K, Conlon PJ, Kheirelseid EA, Aherne T, Walsh SR, Leahy A. Arteriovenous fistula in dialysis patients: Factors implicated in early and late AVF maturation failure. Surgeon 2016; 14(5): 294-300.
    Pubmed CrossRef
  3. Lauvao LS, Ihnat DM, Goshima KR, Chavez L, Gruessner AC, Mills JL Sr. Vein diameter is the major predictor of fistula maturation. J Vasc Surg 2009; 49(6): 1499-504.
    Pubmed CrossRef
  4. Lok CE, Sontrop JM, Tomlinson G, Rajan D, Cattral M, Oreopoulos G, et al. Cumulative patency of contemporary fistulas versus grafts (2000-2010). Clin J Am Soc Nephrol 2013; 8(5): 810-8.
    Pubmed KoreaMed CrossRef
  5. Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75(4 Suppl 2): S1-S164.
    Pubmed CrossRef
  6. Dixon BS, Beck GJ, Vazquez MA, Greenberg A, Delmez JA, Allon M, et al. Effect of dipyridamole plus aspirin on hemodialysis graft patency. The New England journal of medicine 2009; 360(21): 2191-201.
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