Home hemodialysis

Home hemodialysis (HHD), is the provision of hemodialysis in the home of people with stage 5 chronic kidney disease. Home hemodialysis was the most common method of renal replacement therapy in the early 1970s before the introduction of peritoneal dialysis (in the late 1970s), at which point it went into decline. In 2002 HHD began a resurgence in the United States with the introduction of machines designed solely for home use.

People on home hemodialysis are followed by a nephrologist who writes the dialysis prescription and they rely on the support of a dialysis unit for back-up treatments and case management. Studies show that HHD improves ones sense of well being because the more one knows about and controls their own treatment the better they are likely to do on dialysis.^[1]

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Home hemodialysis schedules

There are three basic schedules of HHD and these are differentiated by the length and frequency of dialysis and the time of day the dialysis is carried out. They are as follows:

• Conventional HHD - done three times a week for four hours. It is like in-centre hemodialysis (IHD), but done at home.
• Short daily home hemodialysis (SDHHD) - done five to seven times a week for approximately two hours per session.
• Nocturnal home hemodialysis (NHHD) - done 3.5 to seven times per week at night.

Thus a NHHD schedule results in a larger dose of hemodialysis per week, as do some SDHHD. More total time dialyzing, shorter periods between treatments and the fact that fluid removal speeds can be lower (thus reducing the symptoms resulting from rapid ultrafiltration), accounts for the advantages of these schedules over conventional ones.

A frequent NHHD schedule has been shown to have better clinical outcomes than a conventional schedule and evidence is mounting that clinical outcomes are improved with each increase in treatment frequency. For recent review articles on more frequent dialysis, see ^[2] and ^[3].

Differences between home hemodialysis schedules

• When compared with the other schedules, nocturnal dialysis results in reduced strain on the heart during dialysis - the pump speed in nocturnal dialysis is lower than in IHD (and SDHHD), 200-300 ml/min versus 300-400 ml/min.
• When compared with other schedules, nocturnal dialysis results in higher clearance of large and medium-sized molecules (that are diffusion-limited).
• Nocturnal dialysis and SDHHD treatment regimens provide a higher dialysis dose^[4]; they have a higher a std Kt/V and HDP than IHD treatment regimens.
• Short dialysis (at home) five times a week is thought to reduce renal osteodystrophy.^[5]
• SDHHD and nocturnal dialysis avoid large fluid shifts typical in IHD (that can cause nausea, cramping, and 'wash-out') after dialysis sessions.

Advantages of nocturnal home hemodialysis

• Better blood pressure management^[6] - less blood pressure medications.
• Avoidance of intradialytic hypotension (i.e. low blood pressure during dialysis), something relatively common in IHD.
• More energy and less 'wash-out' after treatment.
• Decreased prevalence of sleep apnea or improvement in severe cases of sleep apnea - sleep better.
• Less expensive overall for the health system due to lower rates of hospitalization^[7] and savings on nursing.
• Less dietary restrictions – e.g. phosphate binders, renal failure food restrictions.^[8]
• More control over the dialysis treatment schedule and greater life satisfaction.^[9]
• Live longer, according to a case-cohort study.^[10]
• Cardiovacular disease in ESRD patients is the leading cause of mortality.^[11][12] Nocturnal hemodialysis is thought to improve ejection fraction^[13] (an important measure of cardiac function) and lead to a regression in left ventricular hypertrophy.^[14] To further assess this a randomized controlled trial is currently being done.^[15]

Disadvantages of nocturnal home hemodialysis

• Training is needed (typically six weeks - at which time one is dialysed in-centre)
• May cause stresses in relationships.
• Space for the dialysis machine is needed.
• Alarms from the dialysis machine will occasionally disturb the patient's sleep. Experience from Lynchburg^[16] suggests it happens once every 10 days for people using a fistula and 1-2 times per night if using a catheter.

Barriers to home hemodialysis

Knowledge barriers

• Lack of awareness amongst patients - most patients with kidney disease in the USA are not informed of home hemodialysis as a treatment option for end-stage renal disease. One US study^[17] found that 36% of patients did not have contact with a nephrologist until less than 4 months prior to their first dialysis session and that only 12% of patients were offered home hemodialysis as a treatment option.
• Lack of awareness for nephrologists. The lack of familiarity with home hemodialysis makes them less likely to offer it to suitable patients.

Patient factors

• Disability or frailty.
• Patient fear of needles/self-canulation.^[18]
• Patient belief that they will get better care in hospital.^[18]
• Lack of significant other to assist with HHD. Some clinics require a significant other and require that the significant other is trained.
• Desire to compartmentalize disease - avoid creating a "sick home"; wish to think of illness only at treatment center.

Health care funding models

• Although cheaper than unit based hemodialysis, home hemodialysis is still far more expensive than renal transplantation, which remains the cheapest long term renal replacement therapy
• The way doctors are compensated in many jurisdictions is not structured to facilitate/encourage NHHD; in the USA most kidney doctors are not paid for discussing different treatment options with their patients.^[17]
• Many dialysis providers are for-profit enterprises in the USA and would lose money in the short term from switching to HHD from IHD; HHD requires a large initial capital expenditure, as each HHD patient requires their own dialysis machine and lengthy (expensive) training. Significant savings and benefits (for the society) from HHD are realized in the long-term because of
  1. better health outcomes for patients and lower rates of hospitalization,
  2. higher productivity of ERSD patients (more can hold down steady jobs and contribute to society) and
  3. lower (nursing) labour costs.

Dialysis centres only stand to benefit from (3) (lower nursing costs), as the other costs, as currently structured, are externalized to society.

History of home hemodialysis

Home hemodialysis started in the early 1960s. Who started it is in dispute. Groups in Boston, London, Seattle^[19] and Hokkaidō all have a claim.

The Hokkaidō group was slightly ahead of the others, with Nosé's publication of his PhD thesis (in 1962), which described treating patients outside of the hospital for acute renal failure due to drug overdoses. In 1963, he attempted to publish these cases in the ASAIO Journal but was unsuccessful, which was latter described in the ASAIO Journal when people were invited to write about unconventional/crazy rejected papers.^[20] That these treatments took place in people's homes is hotly disputed by Shaldon^[21] and he has accused Nosé of a faulty memory and not being completely honest, as allegendly revealed by some shared Polish Vodka, many years earlier.

The Seattle group (originally the Seattle Artificial Kidney Center, later the Northwest Kidney Centers) started their home program in July of 1964. It was inspired by the fifteen year old daughter of a collaborator's friend, who went into renal failure due to lupus erythematosus, and had been denied access to dialysis by their patient selection committee. Dialysis treatment at home was the only alternative and managed to extend her life another four years.

In the September of 1964 the London group (lead by Shaldon) started dialysis treatment at home. In the late 1960s, Shaldon introduced HHD in Germany.^[22]

Home hemodialysis machines have changed considerably since the inception of the practice. Nosé's machine consisted of a coil (to transport the blood) placed in a household (electric) washing machine filled with dialysate. It did not have a pump and blood transport through the coil was dependent on the patient's heart. The dialysate was circulated by turning on the washing machine (which mixed the dialysate and resulted in some convection) and Nosé's experiments show that this indeed improved the clearance of toxins.

In the USA there has been a large decline in home hemodialysis over the past 30 years. In the early 1970s, approximately 40% of patients used it. Today, it is used by approximately 0.4%.^[19] In other countries HNHD use is much higher. In Australia approximately 11% of ESRD patients use HNHD.^[19]

The large decline in HHD seen in the 1970s and early 1980s is due to several factors. It coincides with the introduction and arise of continuous ambulatory peritoneal dialysis (CAPD) in the late 1970s, an increase in the age and the number of comorbidities (degree of "sickness") in the ESRD population, and, in some countries such USA, changes in how dialysis care is funded (which lead to more hospital-based hemodialysis).

Home night-time (nocturnal) hemodialysis was first introduced by Baillod et al.^[23] in the UK and grew popular in some centers, such as the Northwest Kidney Centers, but then declined in the 1970s (coinciding with the decline in HHD). Since the early 1990s, NHHD has become more popular again. Uldall^[24] and Pierratos ^[25][26] started a program in Toronto, which advocated long night-time treatments, (and coined the term 'nocturnal home hemodialysis') and Agar^[8] in Geelong converted his HHD patients to NHHD.

Equipment

  Currently, two companies in the United States have FDA approved home hemodialysis equipment available. They are made by Fresenius and NxStage. The systems take different approaches to the process of dialysis. The Fresenius "Baby K" home machine is close to a standard hemodialysis machines, but somewhat more user friendly and smaller. The Fresenius Baby K requires a separate reverse osmosis water treatment system which allow dialysate flow rates generally from 300 to 800m ml/minute.

The NxStage System One cycler uses far less dialysate per treatment with a maximum dialysate flow rate of 200 ml/minute but generally runs at rates less than 150 ml/minute. The NxStage System One can be used with bags of ultrapure dialysate - from 15 to 60 liters per treatment (see photo showing treatment in process). This allows the System One to be transportable; as of 2007 the company supports travel within the continental US. Generally, the supplies including the dialysate are delivered as they are scheduled to be used, either bimonthly or monthly but the amount of supplies can become a concern. The System One can also use a separate dialysate production device manufactured by NxStage - the PureFlow. The PureFlow uses a deionization process to create a 60 liter batch of dialysate. A batch has a 72 hour shelf life and is usually used for two or three treatments, although some patients are using the entire 60 liter batch for a single extended treatment.

References

See also

• Hemodialysis
• Peritoneal dialysis
• Chronic renal failure
• Nephrology

First person accounts/web sites of people with kidney disease

• Nocturnal Home Hemodialysis - A First Person Account (from Toronto) Part 1 Part 2
• Dailyhemo - a kidney patient's web site complete with web forum.
• Nightly Home Hemodialysis Program - Several Testimonials from Lynchburg.

History of home hemodialysis

• The History of Home Hemodialysis: A View From Seattle - a freely available article by CR Blagg.