Home hemodialysis Totally Explained

Everything about Home Hemodialysis totally explained

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 patients' sense of well-being; the more they know about and control their own treatment the better they're 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 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 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 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; they've 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.

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 - less blood pressure medications.

Avoidance of intradialytic hypotension (for example 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 and savings on nursing.

Less dietary restrictions – for example phosphate binders, renal failure food restrictions.

More control over the dialysis treatment schedule and greater life satisfaction.

Live longer, according to a case-cohort study.

Cardiovacular 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. To further assess this a randomized controlled trial is currently being done.

Disadvantages of nocturnal home hemodialysis

Training is 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 for example 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 Lynchburg 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 found that 36% of patients didn't 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.

Patient belief that that'll get better care in hospital. 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's 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.
   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 didn't 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's used by approximately 0.4%. 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.

Equipment

Currently, three companies in the United States have FDA approved home hemodialysis equipment available. 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 2007 the company supports travel within the continental US. Generally, the supplies including the dialysate are delivered as they're 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.

Further Information

Get more info on 'Home Hemodialysis'.

External Link Exchanges

Do you know how hard it is to get a link from a large encyclopaedia? Well we're different and will prove it. To get a link from us just add the following HTML to your site on a relevant page:

<a href="http://home_hemodialysis.totallyexplained.com">Home hemodialysis Totally Explained</a>

Then simply click through this link from your web page. Our crawlers will verify your link, extract the title of your web page and instantly add a link back to it. If you like you can remove the words Totally Explained and embed the link in article text.
As long as your link remains in place, we'll keep our link to you right here. Please play fair - our crawlers are watching. Your site must be closely related to this one's topic. Any kind of spamming, dubious practises or removing the link will result in your link from us being dropped and, potentially, your whole site being banned.