Home hemodialysis

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Home hemodialysis (HHD), is the provision of hemodialysis to purify the blood of a person whose kidneys are not working normally, in their own home.

Patients who are being treated with home hemodialysis are under the care of a nephrologist who writes the dialysis prescription. The patients rely on the support of a dialysis unit for back-up treatments and case management. Various studies over the years have reported that HHD improves patients' sense of well-being. Basically, the more patients know about and control their own treatment, the better they are likely to do on home dialysis.

Video Home hemodialysis

Schedules

There are three basic schedules of HHD, which are differentiated by the length and frequency of dialysis, plus the time of day the dialysis is performed. They are as follows:

• Conventional HHD--performed three times a week for 3-5 hours. It is like in-center hemodialysis (IHD), but conducted at home. Some patients use a modified conventional "EOD" (Every Other Day) strategy in which treatments are performed an average of 3.5 times a week. It is generally accepted that the "3 day gap" that occurs once a week in conventional HHD on the normal 3x/week schedule increases the risk to the patient.
• Short daily home hemodialysis (SDHHD) -- performed 5-7 times a week, for 2-4 hours per session.
• Nocturnal home hemodialysis (NHHD) -- performed 3-7 times per week at night during sleep, for 6-10 hours.

Thus, an NHHD schedule results in a larger dose of hemodialysis per week, as do some SDHHD. It widely believed that more total time dialyzing, shorter periods between treatments, and the fact that fluid removal speeds can be slower (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 result in better clinical outcomes than a conventional schedule. In addition, evidence is mounting that clinical outcomes are improved with each increase in treatment frequency.

Differences between home hemodialysis schedules

• When compared with the other schedules, nocturnal dialysis results in reduced strain on the heart during dialysis--the ultrafiltration rate (UFR) in nocturnal dialysis is lower than in CHD (and SDHHD).
• Frequent nocturnal hemodialysis can improve left ventricular mass measures, reduce the need for blood pressure medications, improve some measures of mineral metabolism, and improve selected measures of quality of life.
• 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; they have a higher std Kt/V and HDP than do IHD treatment regimens.
• Short dialysis (at home) five times a week is thought to reduce renal osteodystrophy.
• SDHHD and nocturnal dialysis avoid large fluid shifts typical in IHD (that can cause nausea, cramping and "wash-out") after dialysis sessions.

Maps Home hemodialysis

Advantages of nocturnal home hemodialysis

• Better blood pressure management--less need for blood pressure medications.
• Avoidance of intradialytic hypotension (i.e. low blood pressure during dialysis), something that is 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, so that the patient sleeps better.
• Less expensive overall for government-reimbursed health systems, due to the lower reported rates of hospitalization and savings on nursing.
• Less dietary restrictions -- e.g., phosphate binders and renal failure food restrictions.
• More control over the dialysis treatment schedule and greater life satisfaction.
• Patients normally live longer, according to a case-cohort study.
• Cardiovascular disease in ESRD patients is the leading cause of mortality. Nocturnal hemodialysis is thought to improve ejection fraction (an important measure of cardiac function) and lead to a regression in left ventricular hypertrophy. Recently a benefit of 6x/week nocturnal hemodialysis on left ventricular hypertrophy was demonstrated in a randomized controlled trial.

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Disadvantages of nocturnal home hemodialysis

• Training is usually conducted during regular business hours, as often as five times a week. Training can routinely take 2-8 week, at which time one is dialyzed incenter, usually in a separate home hemodialysis training unit.
• Introducing dialysis into the home will impact everyone in the home, for good and bad.
• Sufficient space is needed for the dialysis machine and supplies.
• One may face increased utility costs. (Some utilities have pricing accommodations that may be available.)
• Supply management may require time during business hours, e.g. to receive deliveries, to drop off blood draws.
• Home dialysis may require trips to the dialysis center once a month, for iron and case management.
• If nocturnal dialysis is chosen, some night's sleep can be disrupted due to machine alarms. Experiences from Lynchburg suggests it happens once every 10 days for people using a fistula and 1-2 times per night if using a catheter.

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Barriers to home hemodialysis

Knowledge barriers

• Lack of awareness among patients--many patients with kidney disease in the U.S. are not informed of home hemodialysis as a treatment option for end-stage renal disease (ESRD). One U.S. study found that 36% of patients did not have contact with a nephrologist until less than four 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: in general

• Disability or frailty.
• Patient fear of needles/self-cannulation.
• Patient belief that they will receive better care in-hospital.
• Lack of a significant other to assist with conducting HHD. Some clinics require a significant other and require that the significant other be trained.
• Desire to compartmentalize disease--avoid creating a "sick home." They may wish to think that the illness only occurs at their treatment center.
• Having suitable space and facilities, or a suitable area that could be adapted within their home environment.
• Having the ability and motivation to learn to reliably carry out the process.
• Commitment to maintain treatment.
• Patient being stable on dialysis (see next section for further details on adherence issues), free of complications and free from significant concomitant disease that would render home dialysis unsuitable or unsafe.

Patient factors: barriers to home dialysis from nonadherence to regimes

• Fluid adherence is influenced by a heightened sense of thirst.
• Possible cognitive executive functioning issues associated with uremia condition of end state kidney disease. This may affect memory, ability to plan effectively and keeping to schedules.
• High levels of depression and anxiety are also typically associated with end state kidney disease. This often results in significant life style changes, which also contributes to reduced cognitive and behavioral functioning and negative illness schemes. These factors may influence both motivation and capacity for adherence/compliance to regimes.

Patient factors: addressing dialysis nonadherence

• Cognitive Behahavioural Therapy has been shown to be effective with dialysis patients to address levels of depression, specific phobias/fears and to decrease levels of anxiety.
• Use of psychoeducation to assist patient and care givers, understanding and insights into nonadherence issues.

Health care funding models

• Incenter dialysis and home hemodialysis are reimbursed to exactly the same amounts in the U.S. under the ESRD program. From CMS's point of view, any form of dialysis is still more expensive than renal transplantation, if reviewed over a three-year period. A good kidney transplant (one that lasts five years or more) remains the least expensive long-term renal replacement therapy.
• In many jurisdictions, doctors are not compensated to facilitate/encourage home dialysis. In the U.S., most kidney doctors (nephrologists) are not paid for discussing different treatment options with their patients. In fact, compared to the Medicare reimbursement, if the doctor makes weekly rounds incenter, Medicare reimbursement to follow someone at home is less per month.
• In the U.S., to recoup the unreimbursed cost of training, providers need people with Medicare as their primary insurer to dialyze at home for approximately one year. HHD requires a large initial capital expenditure, because each HHD patient requires their own dialysis machine and lengthy (expensive) training. Significant savings and benefits (for the society or taxpayers) 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 ESRD patients (more can hold down steady jobs and contribute to society).
  3. Lower (nursing) labor costs.

Dialysis providers only stand to benefit primarily from lower nursing costs(3), since the other costs such as poorer health(1) and lower productivity(2), as currently structured, are externalized to society, in the opinion of some people. With the expensive training and hemodialysis equipment required, the return on investment is high only for long-term home hemodialysis patients, some experts believe.

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History of home hemodialysis

Home hemodialysis started in the early 1960s, although who exactly started it is in dispute. Groups in Boston, London, Seattle and Hokkaid? all have a claim.

The Hokkaid? group was slightly ahead of the others, with Dr. Nose'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. That these treatments occurred in patient's homes is hotly disputed by Dr. Stanley Shaldon. He has allegedly claimed that Nose may have a faulty memory and was not being completely honest, as reportedly revealed by some shared Polish Vodka, many years earlier.

The Seattle group (originally the Seattle Artificial Kidney Center, which was later renamed the Northwest Kidney Centers) started its home dialysis program in July 1964. It was inspired by the 15-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 her patient selection committee. Dialysis treatment at home was the only alternative, which resulted in an extension of her life by another four years.

Dr. Christopher Blagg has stated that the first training predated the establishment of the home program--the "first home patient wasn't part of our program at all, he was president of a big Indian corporation, lived in Madras, and he came to Seattle just before I came in '63. He came in early '63, again, with his doctor and his wife and Dr. Scribner trained them to do dialysis at home and they went home to Madras."

In September 1964, the London group (led by Dr. Shaldon) started dialysis treatment at home. In the late 1960s, Dr. Shaldon introduced HHD in Germany.

Home hemodialysis machines have changed considerably since the inception of the practice. Dr. 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 Nose's experiments show that this indeed improved the clearance of toxins.

In the United States, 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%. In other countries, HNHD use is much higher. In Australia, approximately 11% of ESRD patients use HNHD.

The large decline in HHD seen in the 1970s and early 1980s appears to be due to several factors. It coincides with the introduction and rise of continuous ambulatory peritoneal dialysis (CAPD) in the late 1970s, an increase in the age and number of comorbidities (degree of "sickness") in the ESRD population, and in some countries such as the U.S., changes in how dialysis care is funded or reimbursed by the government (taxpayers), which led to more hospital-based hemodialysis.

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

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Equipment

Currently, at least three hemodialysis machines are used for home hemodialysis in the United States. They are manufactured by B Braun, Fresenius and NxStage. The systems take different approaches to the process of dialysis. The B Braun is a standard hemodialysis machine that is used incenter and at home. The Fresenius "Baby K" home machine is close to standard hemodialysis machines, but somewhat more user friendly and smaller. Both the B Braun and the Fresenius Baby K require a separate reverse osmosis (RO) water treatment system that generally allows dialysate flow rates of 300-800 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 that are less than 150 ml/minute. The NxStage System One can be used with bags of ultrapure dialysate--15-60 liters per treatment (see photo showing treatment in process). This allows the System One to be transportable. Since 2008, the company has supported travel within the continental U.S., and will assist travel to Alaska and Hawaii (travel to AK & HI will result in the patient having additional out-of-pocket costs).

In general, the supplies (including the dialysate) are delivered according to when 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--called the PureFlow. The PureFlow uses a deionization process to create a 60, 50 or 40 liter batch of dialysate, depending on the bag of dialysate concentrate specified by the physician or nephrologist. One batch has a 96-hour shelf life, and is usually used for 2-3 treatments, although some patients are using the entire 60, 50 or 40 liter batch for a single extended treatment.

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Frequency of hemodialysis

Patients who receive frequent daytime hemodialysis have performed well on short sessions (1.5 hours) that are administered six times per week, although this would total nine hours per week, resulting in fewer hours of treatment per week than most patients who are dialyzed 3x/week. When patients change from a 3x/week to a 6x/week schedule, if total weekly time is left the same (each session length is cut in half), patients typically will still remove slightly more waste products initially than with conventional schedules, since the blood levels of toxins during the initial hour of dialysis are higher than in subsequent hours. Most patients who are treated at home "daily" (6x/week) with daytime hemodialysis, use dialysis session lengths of 2-3 hours. Longer session lengths provide more benefit in terms of fluid and especially, phosphate removal. However, unless sessions are prolonged beyond 3-4 hours, almost all 6x/week patients will still require phosphate binders. Fluid and phosphate removal with "daily" dialysis are also reportedly made more difficult, because home dialysis patients often feel better, since they receive an increased protein (and thus also, phosphate), as well as fluid intake.

When nocturnal dialysis is administered 3 or 3.5 times (every other night) per week, the total weekly duration of dialysis is markedly prolonged, practitioners report, since each session typically lasts 6-8 hours, compared to 3-4 hours for conventional dialysis. This provides benefits in terms of fluid removal and phosphate removal, although about 1/2 to 2/3 of patients receiving this category of treatment will still require phosphate binders. When such long nocturnal sessions are administered 6x/week, in almost all patients, phosphate binders can be stopped, and in a substantial number, phosphate needs to be added to the dialysate, in order to prevent phosphate depletion. Because of the long weekly dialysis time, fluid removal is very well controlled, as the rate of ultrafiltration is quite low.

Whereas adequacy of conventional dialysis is measured by urea reduction ratio URR or Kt/V, the question of adequacy of more frequent dialysis is based on opinion only, and not on controlled trials. The KDOQI 2006 adequacy group, in its clinical practice recommendations, suggested using the Standardized Kt/V as a minimum standard of adequacy for dialysis schedules other than 3x/week. A minimum standardized Kt/V value of 2.0 per week was suggested.

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See also

• Hemodialysis
• Peritoneal dialysis
• Chronic renal failure
• Nephrology

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References

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External links

• Home Dialysis Central--Extensive information on all types of home hemodialysis. This is a virtual community of people who perform dialysis at home who maintain a web forum. The nonprofit group is based in Wisconsin. This article discusses nocturnal dialysis, including the pluses and minuses. Also, this article discusses daily dialysis, including the pluses and minuses. Another article discusses conventional home hemodialysis, including the pluses and minuses.
• Home dialysis information--Educational articles, videos, stories and a home dialysis community.
• Frequently Asked Questions about Nocturnal Home Hemodialysis--Written by the staff of the Toronto NHHD program, based in Canada.
• Home Hemodialysis--Information from the National Kidney Foundation (NKF), based in New York NY USA.
• An E-Mail Debate on the Benefits (or Not) of Home Hemodialysis--www.ikidney.com
• kidneyschool.org--General information about kidney disease, provided by the same group of people as www.homedialysis.org
• renalweb.org--A website page that is devoted to daily, nocturnal and home hemodialysis.
• U.S. NIH National Institutes of Health has a series of booklets on treatment methods for kidney failure. One of the booklets reviews the selection of "the treatment that's right for you." It includes a discussion of the pros and cons of each type of dialysis modalities.
• [1]--Extensive information is posted at www.nocturnaldialysis.org about home hemodialysis, nocturnal hemodialysis, and the benefits and outcomes of extended hour and high-frequency hemodialysis.

First person accounts/websites of people with kidney disease

• CKD Blogs . Blogs that are related to chronic kidney disease.
• Nocturnal Home Hemodialysis--A First Person Account (from Toronto) Part 1 Part 2.
• Dailyhemo--A kidney patient's website that includes a web forum.
• Nightly Home Hemodialysis Program--Several Testimonials from Lynchburg.
• DiscoverDialysis.com--A grandson's blog about the nocturnal hemodialysis he performs at home for his grandfather.

History of home hemodialysis

• The History of Home Hemodialysis: A View From Seattle--A freely available article authored Dr. Christopher R. Blagg, a leading renal physician, of Seattle WA.

Source of article : Wikipedia