Home hemodialysis
Encyclopedia
Home hemodialysis is the provision of hemodialysis
in the home of people with stage 5 chronic kidney disease. In the US home hemodialysis was the most common method of renal replacement therapy
in the early 1970s before the introduction of the Federal ESRD program
under Medicare
. With routine payment for dialysis secured through Medicare incenter hemodialysis quickly became the most common form of renal replacement therapy. In the late 1970s with the advent of peritoneal dialysis
, another form of home dialysis, HHD went into further 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 patients' sense of well-being; the more they know about and control their own treatment the better they are likely to do on dialysis.
Thus an 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 and.
, London
, Seattle 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. That these treatments took place in people's homes is hotly disputed by Shaldon 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 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. Dr. Chris 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 Shaldon) started dialysis treatment at home. In the late 1960s, Shaldon introduced HHD in Germany
.
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%. 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 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. 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 and Pierratos started a program in Toronto
, which advocated long night-time treatments, (and coined the term 'nocturnal home hemodialysis') and Agar in Geelong converted his HHD patients to NHHD.
Currently, three hemodialysis machines are used for home hemodialysis in the United States
. They are made by B Braun
, Fresenius and NxStage
. The systems take different approaches to the process of dialysis. The B Braun is a standard hemodialysis machine is used incenter and at home. The Fresenius "Baby K" home machine is close to a standard hemodialysis machines, but somewhat more user friendly and smaller. Both the B Braun and 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 2008 the company supports travel within the continental US and will assist travel to Alaska and Hawaii (travel to AK & HI will result in the patient having additional out of pocket costs). 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.
Patients on frequent daytime hemodialysis have done well on short sessions (1.5 hours) given 6 times per week, although this would total 9 hours per week, and is fewer hours per week than most patients being dialyzed 3/week. When changing from a 3x/week to a 6x/week schedule, if total weekly time is left the same (each session length cut in half), patients typically will still remove a little bit 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 treating themselves "daily" (6x/week) with daytime hemodialysis use session lengths of 2–3 hours. Longer session lengths give 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 made more difficult because patients often feel better and increase protein (and thus also, phosphate) as well as fluid intake.
Nocturnal hemodialysis
When nocturnal dialysis is given 3 or 3.5 times (every other night) per week, the total weekly duration of dialysis is markedly prolonged, since each session typically lasts 6–8 hours, compared to 3–4 hours for conventional dialysis. This gives benefits in terms of fluid removal and phosphate removal, although about 1/2 to 2/3 of patients receiving this kind of treatment will still require phosphate binders. When such long nocturnal sessions are given 6x/week, in almost all patients phosphate binders can be stopped, and in a substantial number, phosphate needs to be added to the dialysate 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.
Measuring adequacy and minimum levels
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 their 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.
Hemodialysis
In medicine, hemodialysis is a method for removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies .Hemodialysis can be an outpatient or inpatient therapy...
in the home of people with stage 5 chronic kidney disease. In the US home hemodialysis was the most common method of renal replacement therapy
Renal replacement therapy
Renal replacement therapy is a term used to encompass life-supporting treatments for renal failure.It includes:*hemodialysis,*peritoneal dialysis,*hemofiltration and*renal transplantation.These treatments will not cure chronic kidney disease...
in the early 1970s before the introduction of the Federal ESRD program
End Stage Renal Disease (US Federal Program)
In 1972 the US Congress passed legislation authorizing the End Stage Renal Disease program under Medicare. Section 299I of Public Law 92-603, passed by Congress on October 30, 1972, extended Medicare coverage to Americans if they had stage five chronic kidney disease and were otherwise qualified...
under Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
. With routine payment for dialysis secured through Medicare incenter hemodialysis quickly became the most common form of renal replacement therapy. In the late 1970s with the advent of peritoneal dialysis
Peritoneal dialysis
Peritoneal dialysis is a treatment for patients with severe chronic kidney disease. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances are exchanged from the blood...
, another form of home dialysis, HHD went into further 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 patients' sense of well-being; the more they know about and control their own treatment the better they are likely to do on dialysis.
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 three to five 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 two to four hours per session.
- Nocturnal home hemodialysis (NHHD) - done three to seven times per week at night during sleep, for six to ten hours.
Thus an 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 and.
Differences between home hemodialysis schedules
- When compared with the other schedules, nocturnal dialysis results in reduced strain on the heart during dialysis - the ultra filtration 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-limitedDiffusionMolecular diffusion, often called simply diffusion, is the thermal motion of all particles at temperatures above absolute zero. The rate of this movement is a function of temperature, viscosity of the fluid and the size of the particles...
). - Nocturnal dialysis and SDHHD treatment regimens provide a higher dialysis dose; they have a higher a std Kt/V and HDPHemodialysis productHemodialysis product - is a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy.It was proposed by Scribner and Oreopoulous because of their perceived inadequacy of the Kt/V measure of dialysis adequacy...
than IHD treatment regimens. - Short dialysis (at home) five times a week is thought to reduce renal osteodystrophyRenal osteodystrophyRenal osteodystrophy or chronic kidney disease-mineral and bone disorder is a bone pathology, characterized by bone mineralization deficiency, that is a direct result of the electrolyte and endocrine derangements that accompany chronic kidney disease...
. - 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 pressureBlood pressureBlood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
management—less need for blood pressure medicationsAntihypertensiveThe antihypertensives are a class of drugs that are used to treat hypertension . Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from...
. - Avoidance of intradialytic hypotensionHypotensionIn physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
(i.e. low blood pressure during dialysis), something relatively common in IHD. - More energy and less 'wash-out' after treatment.
- Decreased prevalence of sleep apneaSleep apneaSleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
or improvement in severe cases of sleep apnea - sleep better. - Less expensive overall for the health system due to lower rates of hospitalization and savings on nursing.
- Less dietary restrictions—e.g., phosphate bindersPhosphate bindersPhosphate binders are a group of medications used to reduce the absorption of phosphate and taken with meals and snacks. They are typically used in patients with chronic renal failure as they cannot get rid of the phosphates that get into their blood Phosphate binders are a group of medications...
, renal failure food restrictions. - More control over the dialysis treatment schedule and greater life satisfaction.
- 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 fractionEjection fractionIn cardiovascular physiology, ejection fraction is the fraction of Blood pumped out of the Right Ventricle of the heart to the Pulmonary Circulation and Left Ventricle of the heart to the Systemic Circulation with each Heart beat or Cardiac cycle...
(an important measure of cardiac function) and lead to a regression in left ventricular hypertrophyVentricular hypertrophyVentricular hypertrophy is the enlargement of ventricles in the heart. Although left ventricular hypertrophy is more common, enlargement can also occur in the right ventricle, or both ventricles.- Physiology :...
. Recently a benefit of 6x/week nocturnal hemodialysis on left ventricular hypertrophy was demonstrated in a randomized controlled trialRandomized controlled trialA randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
.
Disadvantages of nocturnal home hemodialysis
- Training is usually done during business hours, as often as five times a week. Training can take from 2 to 8 weeks at which time one is dialyzed incenter, often in a separate home hemodialysis training unit.
- Introducing dialysis into the home will impact everyone in the home, for good and bad.
- Space is needed for the dialysis machine and supplies.
- One may face increased utility costs. (Some utilities have accommodations available)
- Supply management may require time during business hours e.g. to receive deliveries, to drop off blood draws.
- May require trip to 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. Experience from LynchburgLynchburg, VirginiaLynchburg is an independent city in the Commonwealth of Virginia. The population was 75,568 as of 2010. Located in the foothills of the Blue Ridge Mountains along the banks of the James River, Lynchburg is known as the "City of Seven Hills" or "The Hill City." Lynchburg was the only major city in...
suggests it happens once every 10 days for people using a fistulaCimino fistulaA Cimino fistula, also Cimino-Brescia fistula, surgically created arteriovenous fistula and arteriovenous fistula , is a type of vascular access for hemodialysis...
and 1-2 times per night if using a catheterDialysis catheterA dialysis catheter is a catheter used for exchanging blood to and from the hemodialysis machine from the patient.The dialysis catheter contains two lumens:*Venous*ArterialThis is a confusing terminology for layperson, because both lumens are in the vein...
.
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 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-cannulation.
- Patient belief that they will get better care in hospital.
- Lack of significant other to assist with HHD. Some clinics require a significant other and require that the significant other be trained.
- Desire to compartmentalize disease - avoid creating a "sick home"; wish to think of illness only at treatment center.
Health care funding models
- Incenter dialysis and home hemodialysis are reimbursed to exactly the same amounts in the United States under the ESRD programEnd Stage Renal Disease (US Federal Program)In 1972 the US Congress passed legislation authorizing the End Stage Renal Disease program under Medicare. Section 299I of Public Law 92-603, passed by Congress on October 30, 1972, extended Medicare coverage to Americans if they had stage five chronic kidney disease and were otherwise qualified...
. From CMS'sMedicare (United States)Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
point of view any form of dialysis is still more expensive than renal transplantation if looked at over a three year period. A good kidney transplant (one that lasts five years) remains the cheapest long term renal replacement therapyRenal replacement therapyRenal replacement therapy is a term used to encompass life-supporting treatments for renal failure.It includes:*hemodialysis,*peritoneal dialysis,*hemofiltration and*renal transplantation.These treatments will not cure chronic kidney disease...
. - In many jurisdictions doctors are not compensated to facilitate/encourage home dialysis; in the USA most kidney doctors are not paid for discussing different treatment options with their patients. In fact compared to the MedicareMedicare (United States)Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
reimbursement if the doctor rounds incenter weekly, MedicareMedicare (United States)Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
reimbursement to follow someone at home is less per month. - In the US 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, 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
- better health outcomes for patients and lower rates of hospitalization,
- higher productivity of ESRD patients (more can hold down steady jobs and contribute to society) and
- lower (nursing) labour costs.
- Dialysis providers only stand to benefit from (3) (lower nursing costs) as the other costs (1) (poorer health) and (2) (lower productivity), as currently structured, are externalizedExternalityIn economics, an externality is a cost or benefit, not transmitted through prices, incurred by a party who did not agree to the action causing the cost or benefit...
to society. With the expensive training and hemodialysis equipment required, the return on investmentReturn on investmentReturn on investment is one way of considering profits in relation to capital invested. Return on assets , return on net assets , return on capital and return on invested capital are similar measures with variations on how “investment” is defined.Marketing not only influences net profits but also...
is high only for long-term home hemodialysis patients.
History of home hemodialysis
Home hemodialysis started in the early 1960s. Who started it is in dispute. Groups in BostonBoston
Boston is the capital of and largest city in Massachusetts, and is one of the oldest cities in the United States. The largest city in New England, Boston is regarded as the unofficial "Capital of New England" for its economic and cultural impact on the entire New England region. The city proper had...
, London
London
London is the capital city of :England and the :United Kingdom, the largest metropolitan area in the United Kingdom, and the largest urban zone in the European Union by most measures. Located on the River Thames, London has been a major settlement for two millennia, its history going back to its...
, Seattle and Hokkaidō all have a claim.
The Hokkaidō
Hokkaido
, formerly known as Ezo, Yezo, Yeso, or Yesso, is Japan's second largest island; it is also the largest and northernmost of Japan's 47 prefectural-level subdivisions. The Tsugaru Strait separates Hokkaido from Honshu, although the two islands are connected by the underwater railway Seikan Tunnel...
group was slightly ahead of the others, with Nosé's publication of his PhD
PHD
PHD may refer to:*Ph.D., a doctorate of philosophy*Ph.D. , a 1980s British group*PHD finger, a protein sequence*PHD Mountain Software, an outdoor clothing and equipment company*PhD Docbook renderer, an XML renderer...
thesis
Thesis
A dissertation or thesis is a document submitted in support of candidature for an academic degree or professional qualification presenting the author's research and findings...
(in 1962), which described treating patients outside of the hospital for acute renal failure
Acute renal failure
Acute kidney injury , previously called acute renal failure , is a rapid loss of kidney function. Its causes are numerous and include low blood volume from any cause, exposure to substances harmful to the kidney, and obstruction of the urinary tract...
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 took place in people's homes is hotly disputed by Shaldon and he has accused Nosé of a faulty memory and not being completely honest, as allegendly revealed by some shared Polish Vodka
Vodka
Vodka , is a distilled beverage. It is composed primarily of water and ethanol with traces of impurities and flavorings. Vodka is made by the distillation of fermented substances such as grains, potatoes, or sometimes fruits....
, many years earlier.
The Seattle group (originally the Seattle Artificial Kidney Center, later the Northwest Kidney Centers
Northwest Kidney Centers
The Northwest Kidney Centers in Seattle Washington was established in 1962 as the first out-of-hospital outpatient hemodialysis treatment center. The model of providing hemodialysis outside of a hospital setting has spread throughout the world...
) started their home program in July 1964. It was inspired by the fifteen year old daughter of a collaborator's friend, who went into renal failure due to lupus erythematosus
Lupus erythematosus
Lupus erythematosus is a category for a collection of diseases with similar underlying problems with immunity . Symptoms of these diseases can affect many different body systems, including joints, skin, kidneys, blood cells, heart, and lungs...
, 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. Dr. Chris 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 Shaldon) started dialysis treatment at home. In the late 1960s, Shaldon introduced HHD in Germany
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
.
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
Convection
Convection is the movement of molecules within fluids and rheids. It cannot take place in solids, since neither bulk current flows nor significant diffusion can take place in solids....
) 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%. 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 is due to several factors. It coincides with the introduction and arise of continuous ambulatory peritoneal dialysis
Peritoneal dialysis
Peritoneal dialysis is a treatment for patients with severe chronic kidney disease. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances are exchanged from the blood...
(CAPD) in the late 1970s, an increase in the age and the number of comorbidities
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
(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. in the UK
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
and grew popular in some centers, such as the Northwest Kidney Centers
Northwest Kidney Centers
The Northwest Kidney Centers in Seattle Washington was established in 1962 as the first out-of-hospital outpatient hemodialysis treatment center. The model of providing hemodialysis outside of a hospital setting has spread throughout the world...
, but then declined in the 1970s (coinciding with the decline in HHD). Since the early 1990s, NHHD has become more popular again. Uldall and Pierratos started a program in Toronto
Toronto
Toronto is the provincial capital of Ontario and the largest city in Canada. It is located in Southern Ontario on the northwestern shore of Lake Ontario. A relatively modern city, Toronto's history dates back to the late-18th century, when its land was first purchased by the British monarchy from...
, which advocated long night-time treatments, (and coined the term 'nocturnal home hemodialysis') and Agar in Geelong converted his HHD patients to NHHD.
Equipment
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
. They are made by B Braun
B. Braun Melsungen
B. Braun Melsungen AG is a German medical and pharmaceutical company, which has offices and facilities in 50 countries. Its headquarters are located in the small town of Melsungen, in central Germany...
, Fresenius and NxStage
NxStage
NxStage Medical, Inc. is a publicly traded company located in Lawrence, Massachusetts. It is a medical device company that develops, manufactures and markets systems for the treatment of end-stage renal disease, acute kidney failure and fluid overload. It received an "honorable mention" in the...
. The systems take different approaches to the process of dialysis. The B Braun is a standard hemodialysis machine is used incenter and at home. The Fresenius "Baby K" home machine is close to a standard hemodialysis machines, but somewhat more user friendly and smaller. Both the B Braun and 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 2008 the company supports travel within the continental US and will assist travel to Alaska and Hawaii (travel to AK & HI will result in the patient having additional out of pocket costs). 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.
Adequacy of frequent (home) hemodialysis
Frequent "daytime" hemodialysisPatients on frequent daytime hemodialysis have done well on short sessions (1.5 hours) given 6 times per week, although this would total 9 hours per week, and is fewer hours per week than most patients being dialyzed 3/week. When changing from a 3x/week to a 6x/week schedule, if total weekly time is left the same (each session length cut in half), patients typically will still remove a little bit 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 treating themselves "daily" (6x/week) with daytime hemodialysis use session lengths of 2–3 hours. Longer session lengths give 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 made more difficult because patients often feel better and increase protein (and thus also, phosphate) as well as fluid intake.
Nocturnal hemodialysis
When nocturnal dialysis is given 3 or 3.5 times (every other night) per week, the total weekly duration of dialysis is markedly prolonged, since each session typically lasts 6–8 hours, compared to 3–4 hours for conventional dialysis. This gives benefits in terms of fluid removal and phosphate removal, although about 1/2 to 2/3 of patients receiving this kind of treatment will still require phosphate binders. When such long nocturnal sessions are given 6x/week, in almost all patients phosphate binders can be stopped, and in a substantial number, phosphate needs to be added to the dialysate 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.
Measuring adequacy and minimum levels
Whereas adequacy of conventional dialysis is measured by urea reduction ratio URR or Kt/V
Kt/V
In medicine, Kt/V is a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy.*K - dialyzer clearance of urea*t - dialysis time*V - volume of distribution of urea, approximately equal to patient's total body water...
, the question of adequacy of more frequent dialysis is based on opinion only and not on controlled trials. The KDOQI 2006 adequacy group, in their Clinical Practice Recommendations, suggested using the Standardized Kt/V
Standardized Kt/V
Standardized Kt/V, also std Kt/V, is a way of measuring dialysis adequacy. It was developed by Frank Gotch and is used in the USA to measure dialysis. Despite the name, it is quite different from 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.
See also
- HemodialysisHemodialysisIn medicine, hemodialysis is a method for removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies .Hemodialysis can be an outpatient or inpatient therapy...
- Peritoneal dialysisPeritoneal dialysisPeritoneal dialysis is a treatment for patients with severe chronic kidney disease. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances are exchanged from the blood...
- Chronic renal failureChronic renal failureChronic kidney disease , also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite...
- NephrologyNephrologyNephrology is a branch of internal medicine and pediatrics dealing with the study of the function and diseases of the kidney.-Scope of the specialty:...
External links
- Home Dialysis Central - extensive information on all types of home hemodialysis - a virtual community of people that do dialysis at home, has a web forum - non-profit, based in WisconsinWisconsinWisconsin is a U.S. state located in the north-central United States and is part of the Midwest. It is bordered by Minnesota to the west, Iowa to the southwest, Illinois to the south, Lake Michigan to the east, Michigan to the northeast, and Lake Superior to the north. Wisconsin's capital is...
. This article discusses nocturnal dialysis, including the pluses and minuses. This article discusses daily dialysis, including the pluses and minuses. This 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 staff of the Toronto NHHD program.
- Home Hemodialysis – information from the (US) National Kidney Foundation.
- An E-Mail Debate on the Benefits (or Not) of Home Hemodialysis - ikidney.com
- kidneyschool.org - general information about kidney disease - same group of people as homedialysis.org.
- renalweb.org - a page devoted to daily, nocturnal & home hemodialysis
- The US NIH has a series of booklets on treatment methods for kidney failure. One of the booklets is about choosing "the treatment that's right for you" - discusses the pros and cons of type of each dialysis modality.
- http://www.nocturnaldialysis.org - extensive information is available at nocturnaldialysis.org about home hemodialysis, nocturnal hemodialysis and the benefits and outcomes of extended hour and high frequency hemodialysis
First person accounts/web sites of people with kidney disease
- CKD Blogs - blogs related to chronic kidney disease
- Nocturnal Home Hemodialysis - A First Person Account (from TorontoTorontoToronto is the provincial capital of Ontario and the largest city in Canada. It is located in Southern Ontario on the northwestern shore of Lake Ontario. A relatively modern city, Toronto's history dates back to the late-18th century, when its land was first purchased by the British monarchy from...
) Part 1 Part 2 - Dailyhemo - a kidney patient's web site complete with web forum.
- Nightly Home Hemodialysis Program - Several Testimonials from LynchburgLynchburg, VirginiaLynchburg is an independent city in the Commonwealth of Virginia. The population was 75,568 as of 2010. Located in the foothills of the Blue Ridge Mountains along the banks of the James River, Lynchburg is known as the "City of Seven Hills" or "The Hill City." Lynchburg was the only major city in...
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History of home hemodialysis
- The History of Home Hemodialysis: A View From Seattle - a freely available article by CR Blagg.