Home hemodialysis

Home hemodialysis (HHD), or home hemo, is a form of renal replacement therapy. It is carried out in the home (as opposed to in a hospital or clinic). Almost without exception, it is for patients with chronic renal failure.

Types of home hemodialysis

There are three basic types 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 home hemodialysis - 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.
Home nocturnal hemodialysis HNHD (also nocturnal home hemodialysis) - done 3.5 to seven times per week at night.

Most of this article focuses on HNHD, as it has become the most popular type of HHD.

Differences between NHHD, SDHHD and IHD

When compared with SDHHD and IHD, NHHD results in reduced strain on the heart during dialysis - the pump speed in HNHD is lower than in IHD (and SDHHD), 200-300 ml/min versus 300-400 ml/min.
When compared with SDHHD and IHD, NHHD results in higher clearance of large and medium-sized molecules (that are diffusion-limited).
NHHD and SDHHD treatment regimens provide a higher dialysis doseGreene T. What did we learn from the HEMO Study? Implications of secondary analyses. Contrib Nephrol. 2005;149:69-82. PMID 15876830; they have a higher a std Kt/V and HDP than IHD treatment regimens.
NHHD is better than SDHHD, which is better than IHD, at approximating the function of a native kidney.
Short dialysis (at home) five times a week is thought to reduce renal osteodystrophy.Bonomini V, Mioli V, Albertazzi A, Scolari P. Daily-dialysis programme: indications and results. Nephrol Dial Transplant. 1998 Nov;13(11):2774-7; discussion 2777-8. PMID 9829478 Full Text.
Large fluid shifts typical in IHD (that can cause nausea and 'wash-out') after dialysis sessions are avoided.

Advantages of nocturnal home hemodialysis

Better blood pressure managementChan CT, Jain V, Picton P, Pierratos A, Floras JS. Nocturnal hemodialysis increases arterial baroreflex sensitivity and compliance and normalizes blood pressure of hypertensive patients with end-stage renal disease. Kidney Int. 2005 Jul;68(1):338-44. PMID 15954925. Full Text - 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.
Increased fertility - most female end-stage renal disease (ESRD) patients treated with IHD stop menstruating and are infertile. On NHHD, a woman with ESRD managed to get pregnant and have a full-term baby.Gangji AS, Windrim R, Gandhi S, Silverman JA, Chan CT. Successful pregnancy with nocturnal hemodialysis. Am J Kidney Dis. 2004 Nov;44(5):912-6. PMID 15492959.
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 hospitalizationBergman A, Fenton S, Richardson R, Chan C. Reduction in hospitalisations with nocturnal hemodialysis. J. Am. Soc. Nephrol. 2004; 15: 188A. and savings on nursing.
Total dietary and fluid intake freedom or less dietary restrictions – e.g. discontinuation of phosphate binders, renal failure food restrictions.Agar JW. Nocturnal haemodialysis in Australia and New Zealand. Nephrology (Carlton). 2005 Jun;10(3):222-30. PMID 1595 8033. Full Text.
More control over the dialysis treatment schedule and greater life satisfaction.Morris PL, Jones B. Life satisfaction across treatment methods for patients with end-stage renal failure. Med J Aust. 1989 Apr 17;150(8):428-32. PMID 2654590.
Live longer, according to a case-cohort study.Saner E, Nitsch D, Descoeudres C, Frey FJ, Uehlinger DE. Outcome of home haemodialysis patients: a case-cohort study. Nephrol Dial Transplant. 2005 Mar;20(3):604-10. Epub 2005 Jan 21. PMID 15665030 Full Text.
Cardiovacular disease in ESRD patients is the leading cause of mortality.Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, McAlister F, Garg AX. Chronic Kidney Disease and Mortality Risk: A Systematic Review.

J Am Soc Nephrol. 2006 May 31; PMID 16738019.Perazella MA, Khan S. Increased mortality in chronic kidney disease: a call to action. Am J Med Sci. 2006 Mar;331(3):150-3. PMID 16538076. Nocturnal hemodialysis is thought to improve ejection fractionChan C, Floras JS, Miller JA, Pierratos A. Improvement in ejection fraction by nocturnal haemodialysis in end-stage renal failure patients with coexisting heart failure. Nephrol Dial Transplant. 2002 Aug;17(8):1518-21. PMID 12147805. Free Full Text (an important measure of cardiac function) and lead to a regression in left ventricular hypertrophy.Chan CT, Floras JS, Miller JA, Richardson RM, Pierratos A. Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis. Kidney Int. 2002 Jun;61(6):2235-9. PMID 12028465. To further assess this a randomized controlled trial is currently being done.Walsh M, Manns BJ, Klarenbach S, Quinn R, Tonelli M, Culleton BF. The effects of nocturnal hemodialysis compared to conventional hemodialysis on change in left ventricular mass: rationale and study design of a randomized controlled pilot study. BMC Nephrol. 2006 Feb 22;7:2. PMID 16504054. Free Full Text.

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 LynchburgHome Dialysis Central, Types of Home Dialysis: Nocturnal Home Hemodialysis, URL: http://homedialysis.org/v1/types/nhh_01.shtml#10, Accessed on July 15, 2005. 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 treament option for end-stage renal disease. One US studyMehrotra R, Marsh D, Vonesh E, Peters V, Nissenson A. Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney Int. 2005 Jul;68(1):378-90. PMID 15954930. 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 training for nephrologists (kidney doctors) - nephrologists in many parts of the world are not trained to treat patients with home hemodialysis. The lack of familiarity with home hemodialysis makes them less likely to offer it to suitable patients.

Patient factors

Significant disability - blindness, paralysis.
Patient fear of needles/self-canulation.McLaughlin K, Manns B, Mortis G, Hons R, Taub K. Why patients with ESRD do not select self-care dialysis as a treatment option. Am J Kidney Dis. 2003 Feb;41(2):380-5. PMID 12552500.
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 is trained.
Desire to isolate sickness to hospital - avoid creating a "sick home"

Health care funding models

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.
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, SeattleBlagg CR. Home haemodialysis: 'home, home, sweet, sweet home!'. Nephrology (Carlton). 2005 Jun;10(3):206-14. PMID 15958031. and Hokkaido all have a claim.

The Hokkaido 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.Nose Y. Home hemodialysis: a crazy idea in 1963: a memoir. ASAIO J. 2000 Jan-Feb;46(1):13-7. PMID 10667707. That these treatments took place in people's homes is hotly disputed by ShaldonShaldon S. The history of home hemodialysis in Japan. ASAIO J. 2002 Sep-Oct;48(5):577; author reply 577-8. PMID 12296582. 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 started their 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 the University Hospital's dialysis centre 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.Shaldon S. Early history of home hemodialysis in the Federal Republic of Germany. ASAIO J. 2004 Jul-Aug;50(4):291-3. PMID 15307535.

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.Baillod R, Comty C Shaldon S. Overnight haemodialysis in the home. Proc. Eur. Dial. Transplant. Assoc. 1965; 2: 99-104. in the UK and grew popular in some centres, such as Seattle, but then declined in the 1970s (coinciding with the decline in HHD). Since the early 1990s, NHHD has become more popular again. UldallUldall R, Ouwendyk M, Francoeur R, Wallace L, Sit W, Vas S, Pierratos A. Slow nocturnal home hemodialysis at the Wellesley Hospital. Adv Ren Replace Ther. 1996 Apr;3(2):133-6. PMID 8814919. and Pierratos Pierratos A, Ouwendyk M, Francoeur R, Wallace L, Sit W, Vas S, Uldall R, Slow Nocturnal Home Hemodialysis, Dialysis & Transplantation, 1995 Oct;24(10):557. Full Text.Pierratos A, Ouwendyk M, Francoeur R, Vas S, Raj DS, Ecclestone AM, Langos V, Uldall R. Nocturnal hemodialysis: three-year experience. J Am Soc Nephrol. 1998 May;9(5):859-68. PMID 9596084. 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.

References

External links

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
homedialysis.org - a virtual community of people that do dialysis at home, has a web forum - based in Wisconsin. This article discusses the pluses and minuses of NHHD.
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.

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.