Home Hemodialysis: A Patient's Perspective

This is a personal story of a member of a family with hereditary nephritis. My oldest brother died in 1946 before there was any dialysis or transplantation in the United States. My other brother died at the age of 22 in 1960 after unsuccessful kidney transplantation. I developed renal failure in 1980 and was lucky to survive due to the combination of several factors. The first, and most important, was the choice of home hemodialysis, which offers the longest patient survival of all dialysis modalities. The second was the help of my wife, who is my dialysis partner. The third was my conviction that it is not possible to get too much dialysis. I took control of my treatment and insisted on having the largest available dialyzers and performed long dialysis sessions. I was able to continue to work for the first 15 years on dialysis. As I look to the future, I am excited about the prospect of daily home hemodialysis, because I believe that this therapy will offer more efficient treatment and a nearly normal diet.     

Establishing a Home Nocturnal Hemodialysis Program: "Starting From Scratch"

Several types of dialyzers with enhanced internal filtration have been introduced in order to increase solute clearance, especially in relatively larger molecular solutes. In these dialyzers, enhanced internal filtration increased convective transport of the solute in addition to diffusive transport. The internal filtration flow rate (Q_IF) has not, however, been measured in clinical situations, because none of monitoring techniques can measure this value. Herein, the Q_IF value was estimated during an experimental and an analytical study. Namely, we measured blood flow velocity in a cross-sectional plane of the dialyzer by pulse Doppler ultrasonography. An in vitro study with bovine blood was carried out to determine the local blood flow velocity profile with a newly designed probe slider that enables parallel movement of the probe along the dialyzer. Furthermore, an analytical model was newly introduced to calculate changes in flow rate and pressure of blood and dialysate streams and solute concentrations along the dialyzer. The Q_IF value could be estimated by a simulation analysis to the experimental data using the analytical model.     

Return on Investment: An Economic Guideline for Selecting Home Daily/Nocturnal Hemodialysis Patients

One of the main symptoms of terminal-stage chronic renal insufficiency is anemia. One of the best applicable methods correcting anemia is using recombinant human erythropoietin preparation. Using recombinant human erythropoietin in patients with terminal-stage chronic renal insufficiency in 90–95% of events had a positive effect, but 5–10% of patient had refraction to erythropoietin, which has spurred the search for new efficient methods correcting anemia. The purpose of the study was to determine the influence of the laser on erythropoiesis and blood acid–alkaline condition (pH) in patients with terminal-stage chronic renal insufficiency. In the course of the study, erythrocytes, hemoglobin, reticulocytes in blood, and blood acid–alkaline condition (pH) were determined. At the beginning of the treatment, all hematological parameters 5 and 15 days after marrow stimulation were defined. 15 days after marrow stimulation with laser, increasing amounts of erythrocytes, hemoglobin, and hematocrit were observed. The initial erythrocyte count was 2.22 ± 0.1 × 10¹²/L, hemoglobin 67.7 ± 3.2 g/L and hematocrit 18.2 ± 1.2%. During the laser treatment, erythrocyte count increased up to 2.9 ± 0.8 × 10¹²/L, hemoglobin up to 89.6 ± 2.9 g/L and hematocrit up to 28.2 ± 1.3% (p < 0005).     

Experience With Nocturnal Hemodialysis

In order to provide a highly efficient, long-duration form of hemodialysis, we developed nocturnal hemodialysis. Patients were dialyzed nightly at home for 8 – 10 hours, 6 – 7 nights/week. We kept the dialysate flow at 100 mL/min and the blood flow at 250 – 300 mL/min. Patients were monitored remotely from the hospital through a computer connection. An internal jugular line was used as an access. We have trained 12 patients over 30 months and have accumulated 160 patient-months worth of data. The patients tolerated the dialysis very well and slept through the night. There was a significant improvement in their sense of well-being. Nightly Kt/V was 0.99. Weekly removal of phosphate was two times as high and β ₂ -microglobulin four times as high as conventional hemodialysis. All patients have discontinued their phosphate binders and have increased their dietary phosphate and protein intake. Hypertension was controlled with fewer medications, and erythropoietin dosages decreased. Complications were infrequent and included catheter occlusion and infections. Reusing the dialyzers decreased the cost of the treatment to levels similar to continuous ambulatory peritoneal dialysis. Nocturnal hemodialysis represents a viable dialysis modality that combines high quality, low cost, and excellent tolerance.     

Nocturnal Hemodialysis in Australia

Background: Because home hemodialysis has long been a common Australian support modality, the advent of home‐based nocturnal hemodialysis (NHD) in Canada stimulated the extension of our existing home‐ and satellite‐based conventional hemodialysis (CHD) programs to NHD. As a result, the first government‐funded, home‐based, 6‐nights‐per‐week NHD program in Australia began in July 2001. Methods: Sixteen patients have been trained for NHD; 13 dialyzed at home 8 to 9 hr per night for 6 nights per week, whereas 3 preferred to train for NHD at home using an 8‐ to 9‐hr alternate‐night regime. Results: The program experience to March 1, 2003, was 655 patient‐weeks. Two patients had withdrawn for transplantation and 2 for social reasons, although 1 continues on alternate‐night NHD. There hade been no deaths. Ten patients had dialyzed without partners. All patients ceased phosphate binders at entry. Thirteen of 16 discontinued all antihypertensive drugs. There were no fluid or dietary restrictions. Phosphate was added to the dialysate to prevent hypophosphatemia. Pre‐ and postdialysis urea and phosphate levels were broadly within the normal ranges. All patients reported restorative sleep; similarly partners reported stable sleep patterns and noted improved mood, cognitive function, and marital relationships in their NHD partners. Preliminary cost analyses show that whereas consumables had doubled, and epoetin and iron expenditures had risen by 28.9%, other pharmaceutical costs had fallen by 47%, and nursing wage costs were 48% of the notional cost had these patients remained on CHD. Three patients on NHD were retired, 7 worked full‐time, 3 worked part‐time, and 3 drew disability support, whereas previously on CHD, 3 were retired, 3 had worked full‐time, 3 had worked part‐time, and 7 had drawn disability support. Conclusion: We believe that NHD is viable, safe, effective, and well accepted with significant lifestyle benefits and reemployment outcomes. Although initial setup costs are significant, NHD cost advantage over CHD progressively accrues as program numbers exceed 12 to 15 patients.     

Remote Monitoring of Daily Nocturnal Hemodialysis

Daily nocturnal hemodialysis (DNHD) is a new variant of home hemodialysis that allows patients to dialyze at home, at night, while they sleep, providing longer duration and greater frequency of treatments. This paper describes a 3‐year experience with remote monitoring of DNHD patients over the Internet, and we review the remote monitoring experience of the Toronto program, which pioneered DNHD. Technology, structure, and costs are reviewed. Remote monitoring enhanced safety, accuracy of data collection, patient catchment area, and the overall comfort of patients, providers, and regulators.     

Delayed Dialyzer Reprocessing for Home Hemodialysis

Although dialyzer reuse for home hemodialysis (done by patients at home) has been in practice since the 1960s, it is now almost completely abandoned. The need for dialyzer reuse resurfaced with the renewed interest in daily/nightly forms of home hemodialysis and the associated increase in operating costs. We describe a method of dialyzer reuse based on reprocessing of dialyzers at the center, after they had been stored in a refrigerator at home for 1 week by the patient. Transportation of the dialyzers by either the patient or a transportation service was acceptable to the patients. Despite the lower number of reuses, possibly related to the delayed processing, dialyzer reuse in this setting provided significant financial benefits. Experience with this process for 3 years has not disclosed any negative effects after the initial logistical issues related to dialyzer transportation were resolved. In summary, weekly dialyzer reprocessing at the center provides a solution to the need for dialyzer reuse for the home hemodialysis patient.     

Evolution of Home Hemodialysis Monitoring Systems

Systems for monitoring hemodialysis patients at home have evolved during the past 30 years. They consist of hardware and software to record dialysis events from the home hemodialysis machine and transmit them to a server, which in turn sends the data to a remote central monitoring center. Most of the parameters monitored are related to machine function and events. At present, the only commonly monitored patient vital functions are pulse and blood pressure. The early systems used direct telephone lines and modem for telecommunication. The use of Internet links reduces the cost of the service and provides fast and safe transmission of the data. The actual value of these monitoring systems, the need for additional monitoring options, indications for specific groups of patients dialyzing at home, and acceptance by patients, physicians, and regulators will require further evaluation.     

The History of Home Hemodialysis: A View From Seattle

Home hemodialysis was first used for the treatment of end-stage renal disease in the early 1960s, primarily as a means of reducing the cost of treatment. It was soon found to be an effective form of treatment that provided patient independence, greater opportunity for rehabilitation, and better survival. In 1973, when the Medicare End-Stage Renal Disease Program began, some 40% of all U.S. dialysis patients were on home hemodialysis, but since then the percentage of patients on this treatment has steadily decreased. There are several reasons for this, one in particular being the lack of availability of suitable equipment. There is now renewed interest in home hemodialysis sparked by the knowledge that new equipment specifically designed for this is being developed, that this is the modality with the best survival rate, greatest opportunity for adequate dialysis and best quality of life, and an interest in the use of daily (or nightly) home hemodialysis. Consequently, more than 30 years later, it appears that home hemodialysis may again become the preferred treatment for many more patients.     

Telematics Service for Home and Satellite Hemodialysis

Home hemodialysis (HD) for the treatment of end-stage renal disease was first implemented about 30 years ago. In this paper the application of telematics monitoring services for supporting patients who need home HD or satellite HD is described. Two modified HD machines were located in two renal units, and a central control station (CCS, UNIX workstation with multimedia PC terminal) was located in another room of the hospital. Bidirectional communication between the modified HD machines and the CCS was managed using ISDN (Integrated Services Digital Network) links. Nine patients had 150 HD sessions performed using these HD machines over a period of 5 months. This system, called the HOMER-D system, provided on-line, remote supervision of the HD machine-related functions and the clinical condition of the patients through measurement of blood pressure, pulse rate, PO₂ (pulse oxymetry), and ECG from the CCS. Any disturbances in the functioning of the HD machines were both visible and audible in the CCS, and the observer could give teleconsultation to the renal unit staff. No major dialysis-associated complications were observed; all data and alarms were transmitted correctly; and patients received adequate HD treatment.     

Nightly Home Hemodialysis: Fifteen Months of Experience in Lynchburg,Virginia

What constitutes adequate dialysis has been debated in the nephrology literature over the past eight years. The mortality rate of patients on dialysis in the United States is about 20% per year. We believed that short and infrequent dialysis sessions contributed to poor outcomes. To improve the results, Lynchburg Nephrology started the nightly home hemodialysis (NHHD) program in September 1997. Ten patients were trained in the first 15 months of the program. Patients dialyzed 7 – 9 hours, 6 nights/week, using the Fresenius 2008H machine. A standard dialysis solution with 2.0 mEq/L potassium, calcium concentration of 3.0 – 3.5 mEq/L was used. Dialysis solution flow rates were 200 – 300 mL/min. Serum phosphate levels were maintained above 2.5 mg/dL by adding 0 – 45 mL Fleet's Phosphosoda to the bicarbonate bath. Patients had marked improvement in quality of life as measured with the SF-36. Blood pressure was better controlled with fewer medications. All phosphate binders were eliminated. Caloric intake and protein intake increased to normal levels as measured by three-day dietary histories pre-NHHD, and at 3, 6, and 12 months on NHHD. Epoetin alfa dosages were reduced by about 50%. Nightly home hemodialysis should be considered as a valuable modality option for end-stage renal disease patients; it is potentially superior to conventional thrice-weekly hemodialysis.     

Comparison of Staff‐Assisted Home Hemodialysis with In‐Center Hemodialysis and In‐Hospital Hemodialysis

Home hemodialysis (HHD) is superior to in‐center hemodialysis (ICHD) in terms of survival, quality of life, and cost‐effectiveness. However, assistance from family members in performing HHD is not always available to patients, and professional assistance for HHD can be cost prohibitive. For certain patients, ICHD can be impractical due to difficulties in transportation, which may necessitate ambulance transportation or hospitalization for in‐hospital hemodialysis (IHHD). We describe 4 patients that have had problems receiving ICHD for various reasons. Two of these patients had problems with transportation, while the other two could not remain on dialysis for the prescribed duration of time and, therefore, received inadequate dialysis. These patients had difficulty while receiving ICHD in meeting the adequacy criteria set by Dialysis Outcomes Quality Initiative. One of these patients had a neuropsychiatric disorder and displayed disruptive behavior. When these 4 patients were switched to staff‐assisted home hemodialysis (SAHD), the dialysis core indicators improved compared with ICHD, and the patients needed significantly fewer hospitalization days. In this paper, we demonstrate that, in patients that cannot be easily transferred, and in patients with neuropsychiatric disorders, SAHD can be a less expensive and more efficacious modality of dialysis.     

Quantitating Dialysis in the Home Hemodialysis Patient: A Simple and Practical Approach

Home hemodialysis is the most cost-effective form of dialysis and is associated with the lowest mortality. Home hemodialysis patients are usually highly motivated, independent, and actively employed. Because of the minimal supervision they require and the fact that they are not in a controlled environment, it is easy to overlook the measurement of their dialysis adequacy. We studied 6 home hemodialysis patients and demonstrated that blood urea measured 30 min before the end of dialysis (Ct-30) is equivalent to that measured 30 min after the end of dialysis (Ct+30). The Kt/V results using Ct-30, Kt/V(Ct-30), were almost equivalent to Kt/V(Ct+30) (p = 0.5). The Kt/V Kt/V(Ct) using blood urea measured at the end of dialysis (Ct) significantly overestimated Kt/V(Ct-30) and Kt/V(Ct+30) (p = 0.007) The calculated percent reduction of urea (PRU) was about 5% less when using Ct-30 compared with Ct (p = 0.001). Taking blood samples 30 min before the end of dialysis for urea kinetics is more convenient for the home dialysis patients, since no other technical aspects of dialysis need their attention. The samples can be delivered to the laboratory the following day, because the blood may be stored in heparinized tubes at 4°C without deterioration of urea and creatinine concentrations. The Kt/V(Ct-30) was almost equal to Kt/V(Ct+30), so there is no longer any concern for the errors introduced by urea rebound. The blood pump must be reduced to 80 mL/min for about 10 sec to eliminate the errors due to fistula and cardiopulmonary recirculation. A simple programmable calculator will facilitate the calculation of accurate results using the Daugirdas second-generation formula.     

Successful Long-Term Central Venous Access; Daily Home Hemodialysis Blood Access

Successful long-term central venous access is a complex subject. The concept of “long term” implies that continued surveillance will be required. This also requires the catheter to be placed, initially, in its best configuration. To achieve long-term performance and durability, a thorough understanding of all aspects related to the catheter, catheter placement, and catheter maintenance is essential.     

Blood Urea Nitrogen Stability: A Feasibility Study for Home Hemodialysis Adequacy Testing Through Mail

Urea kinetic modeling measures the delivered dose of hemodialysis and is used to monitor dialysis adequacy. Obtaining samples for adequacy calculations is a challenge for home hemodialysis (HHD) patients. Ideally, the urea reduction ratio (URR) should be measured at a typical dialysis session; therefore, for HHD patients test specimens should be drawn at home and transferred to a clinical laboratory. Would blood urea nitrogen (BUN) remain stable if samples were mailed to the laboratory? To answer this question, BUN was measured in pre- and postdialysis samples from 20 patients over 8 days of laboratory storage. While BUN values varied among the patient population, neither pre- nor postdialysis values showed any significant variation during the 8-day storage time. These results suggest that BUN values are sufficiently stable for specimens to be drawn at home and mailed to a testing laboratory.     

Knowledge of Home Dialysis Among Inner‐City Satellite Hemodialysis Patients

There is limited use of home renal replacement therapies in the U.S.A. One percent of dialysis patients are on home hemodialysis (HHD) and only 9% undergo peritoneal dialysis (PD). In an effort to better understand this, 161 satellite hemodialysis patients in 6 units in Brooklyn were surveyed. Forty‐eight percent of patients were women, 86% were black, 5% white, 8% Hispanic, and 1% other. Mean age was 49.4 years (range 22 – 69 years). Etiology of renal disease was hypertension (41%), diabetes mellitus (31%), polycystic kidney disease (3%), systemic lupus erythematosus (4%), and other or unknown (21%). Patients were queried about knowledge of and attitudes toward home therapies. Seventy‐nine percent of patients knew of home dialysis. The source of this information was the nephrologist (59%), the social worker (14%), a nurse (8%), other patients (4%), and other sources (15%). Only 10% of patients had ever considered HHD. Fifty‐four percent were afraid to do self‐care at home and 35% were not interested. Surprisingly, only 3% felt they had no reliable helper and 8% felt that their housing was not suitable. Similarly, 78% of patients had been spoken to about PD, but only 11% had considered it. Forty‐one percent were afraid of doing self‐care on PD, and 45% were not interested. We conclude that, although the majority of patients in six inner‐city dialysis units had heard of home dialysis, only a small number ever considered it. As many patients were afraid of doing home therapy, better education about the risks and benefits needs to be disseminated.     

The Safety of Intravenous Ferric Gluconate Self Administered During Routine Home Hemodialysis

Home hemodialysis (HHD) patients are often inconvenienced when intravenous iron preparations are administered. Formerly, these patients received their medication in the clinic on an off-dialysis day or during in-center hemodialysis (HD). For the last 2 years, 5 patients in our HHD program have been receiving intravenous ferric gluconate during their routine HD session.
Procedure:  All patients were trained in the proper administration of ferric gluconate in-center. No test dose was administered. Ferric gluconate was infused via the heparin infusion pump on their HD machine at a rate of 31.25 mg/h. Doses were of either 62.5 mg or 125 mg per session. K/DOQI guidelines for intravenous iron use were adhered to. TSATs greater than 25%, ferritin greater than 100 ng/mL and less than 800 ng/mL, and hemoglobin between 11 and 12 g% were the goals of therapy. Both loading doses (8 doses during sequential HD sessions) and maintenance doses every week or every other week were employed.
Results:  Over the last 2 years, 223 doses were administered at home. No serious reactions occurred during the course of therapy. One patient experienced minor nausea and vomiting during one dose, which was thought to be possibly related to the iron infusion. This patient subsequently received ferric gluconate again without difficulty.
Conclusion:  Ferric gluconate can be safely administered at home during HHD.     

6 Month Experience with 1 Nurse Training 2 Patients Together for Nightly Home Hemodialysis

Purpose:  Nocturnal home hemodialysis (NHHD, 6–7 times weekly 6–9 h) results in better clinical outcome than conventional 3 times weekly hemodialysis. A good training program for patient and partner is a prequisite for success. We developed a training course for patients and partners.
Methods:  Since December 2001, we trained 20 patients and their partners to perform NHHD in 2 succeeding groups. The first group, consisting of 15 patients and their partners, started a NHHD pilot study. During this pilot study, we improved the training course. The second group of 5 were trained with this improved program. All 5 participants were home hemodialysis patients for over 1 month before starting the NHHD course. First, they learned how to handle the single needle system. Then, they performed single needle hemodialysis for 2 weeks at home. This was followed by an in-center NHHD training, consisting of 4 conventional day-time and 3 long (8 h) nocturnal dialysis treatments. Main targets during this training period are to learn to deal with safety precautions, online monitoring, and special machine features, and to check biochemistry and heparinization during long dialysis. 1 month after the training we evaluated the course with all participants.
Results:  For 9 of 15 couples in the first group, the training appeared to be exhausting. Stress factors were an overloaded program and too little experience with several new skills including needle technique before starting NHHD. The second group started the NHHD training 2 weeks after the single needle training. This second group was pleased with the training protocol.
Conclusion:  The training course for NHHD should not be overloaded. Patients need time to learn new skills before starting NHHD.