The ideal home hemodialysis machine

Daily home hemodialysis (HD) patients have a much superior survival rate than patients on regular, 3 times a week in-center HD or on peritoneal dialysis. Present-day HD machines are unsuitable for use at home by patients. We present our concept of the ideal home HD machine that allows daily short and long HD, does all the work preparing for and cleaning up after dialysis, has an intravenous infusion system controlled by the patient, needs no systemic anticoagulation, and teaches and interacts with the patient during dialysis. To fulfill these functionalities, the dialyzer and blood tubing must be integrated with the machine and replaced less often than monthly, the machine must be capable of at least 200 L/week of hemodiafiltration, prepare all fluids necessary between and during dialyses, and all the components and fluids must be much beyond ultrapure.     

International quotidian dialysis registry: Annual report 2010

The International Quotidian Dialysis Registry (IQDR) is a global initiative designed to study practices and outcomes associated with the use of hemodialysis (HD) regimens of increased frequency and/or duration. The IQDR grew out of the initiative that lead to the randomized prospective studies of nocturnal HD and short hours daily dialysis vs. conventional thrice weekly HD that are conducted by the Frequent Hemodialysis Network sponsored by the National Institutes of Health. These 2 separate studies are drawing to a close and the first results are expected to be reported later this year. These studies use surrogate outcomes for their primary endpoints as they are not powered to look at outcomes of mortality and hospitalization. The IQDR attempts to aggregate long‐term follow‐up data from centers utilizing alternative HD regimens worldwide and will have adequate statistical power to examine those important outcomes. To date, the IQDR has enrolled patients from Canada, the United States, Australia, New Zealand, and France and has linked with commercial databases and national registries. This sixth annual report of the IQDR describes: (1) An update on the governance structure; (2) The recommendations made at the first general meetings of the IQDR Scientific Committee and Advisory Board; (3) The status of those recommendations; (4) A summary of current data sources and participating registries; (5) The status of recruitment to date; (6) The creation of a specific Canadian IQDR data set and; (7) The current research agenda.     

The carbon footprints of home and in‐center maintenance hemodialysis in the United Kingdom

Climate change presents a global health threat. However, the provision of healthcare, including dialysis, is associated with greenhouse gas emissions. The aim of this study was to determine the carbon footprints of the differing modalities and treatment regimes used to deliver maintenance hemodialysis (HD), in order to inform carbon reduction strategies at the level of both individual treatments and HD programs. This was a component analysis study adhering to PAS2050. Emissions factors were applied to data that were collected for building energy use, travel and procurement. Thrice weekly in‐center HD has a carbon footprint of 3.8 ton CO₂ Eq per patient per year. The majority of emissions arise within the medical equipment (37%), energy use (21%), and patient travel (20%) sectors. The carbon footprint of providing home HD varies with the regime. For standard machines: 4 times weekly (4 days, 4.5 hours), 4.3 ton CO₂ Eq; 5 times weekly (5 days, 4 hours), 5.1 ton CO₂ Eq; short daily (6 days, 2 hours), 5.2 ton CO₂ Eq; nocturnal (3 nightly, 7 hours), 3.9 ton CO₂ Eq; and nocturnal (6 nightly, 7 hours), 7.2 ton CO₂ Eq. For NxStage equipment: short daily (5.5 days, 3 hours), 1.8 t CO₂ Eq; 6 nightly nocturnal (2.1 ton CO₂ Eq). The carbon footprint of HD is influenced more by the frequency of treatments than by their duration. The anticipated rise in the prevalence of home HD patients, dialyzing more frequently and for longer than in‐center patients, will increase the emissions associated with HD programs (despite reductions in patient travel emissions). Emerging technologies, such as NxStage, might offer a solution to this problem.     

International quotidian dialysis registry: Annual report 2009

The International Quotidian Dialysis Registry (IQDR) is a global initiative designed to study practices and outcomes associated with the use of hemodialysis regimens of increased frequency and/or duration. Several small studies suggest that compared with conventional hemodialysis (HD), short-daily, nocturnal, and long conventional HD regimens may improve surrogate endpoints and quality of life. However, methodologically robust comparisons on hard outcomes are sorely lacking. The IQDR represents the first-ever attempt to aggregate long-term follow-up data from centers utilizing alternative HD regimens worldwide, and will have adequate statistical power to examine the effects of these regimens on multiple clinical endpoints, including mortality. To date, the IQDR has enrolled patients from Canada, the United States, Australia, and New Zealand, with plans in place to begin linking with additional commercial databases and national registries. This fifth annual report of the IQDR describes (1) a proposed governance structure that will facilitate international collaboration, stakeholder input and funding; (2) data sources and participating registries; (3) recruitment to date and patient baseline characteristics; and (4) an agenda for future research.     

Home hemodialysis in Australia: current perspective

Home hemodialysis (HD) in Australia represents 11% of the dialysis population. This percentage has declined over the last 20 years but the absolute number of home HD patients has increased since 2001. The major reason for this resurgence has been the institution of nocturnal HD at home. Predominantly, this has been as a strictly alternate day exercise, although 5-6 times per week dialysis is also practised. Short-daily HD is uncommon in Australia. Nocturnal HD now comprises 30% or more of all home HD. Most home HD in Australia is practiced without remote monitoring, using simple machines with separate reverse osmosis units. Patients tend to self-needle and not all have a "partner." The enthusiasm for nocturnal HD in particular has been fuelled by ANZDATA Registry data demonstrating a survival advantage for patients dialyzing alternate days compared with 3 times per week; and for patients dialyzing for >18 hours per week compared with 12 or 15 hours per week.     

Short and long nightly hemodialysis in the United States

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.     

The International Quotidian Dialysis Registry: annual report 2006

Interest in short daily and nocturnal hemodialysis (HD) regimens continues to grow worldwide. Despite growing optimism that these therapies will afford better patient outcomes over conventional HD, the current literature has not been viewed as sufficiently compelling to affect widespread implementation in most jurisdictions. Before these therapies can gain wider acceptance, larger and more rigorous studies will likely be needed. In June 2004, the Quotidian Dialysis Registry, based at the Lawson Health Research Institute at the University of Western Ontario, Canada, began recruiting patients across North America. By using an Internet-based data entry platform, patients from various centers worldwide will eventually be recruited, and studied prospectively. This paper constitutes the second annual update on patient and center recruitment, patient and treatment characteristics, and future directions for the registry.     

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.     

Heparin Use in Daily Hemodialysis

More frequent dialysis is thought to be associated with increased heparin requirements; however, limited data are available which compare heparin requirements of conventional to daily dialysis. Objectives: To determine differences in heparin dose during conventional thrice‐weekly dialysis (CHD) compared to daily hemodialysis (DHD). Methods: All patients within the daily home hemodialysis at the Northwest Kidney Centers were evaluated for heparin dose both pre‐ and post initiation of daily hemodialysis. Patients on DHD received an initial bolus of heparin, without a continuous heparin drip, and supplemental heparin midway through the dialysis run as needed to maintain adequate activated clotting times (ACTs). CHD patients received a heparin bolus, followed by initiation of heparin drip as needed to maintain adequate ACTs. Results: Of the 1117 patients who dialyze at the NKC, 55% were Caucasian, 21% African‐American, 20% Asian/Pacific Islander, and 35% were of other ethnicity. The majority of patients were greater than 60 years (56%), while 36% ranged from 40–60 years and 13% ranged from 20–40 years. Male patients constituted 54% of patients. Diabetes was the primary cause of renal disease (36%), followed by hypertension (21%) and glomerular disease (18%). Of those patients in the home hemodialysis program (n = 45), 10 patients started daily home hemodialysis using the Aksys daily home hemodialysis system. Of those, the majority was male (100%), Caucasian (78.8%) with an average age of 46.7 ± 18 years. Glomerulonephritis was the primary cause of end‐stage renal disease (40%), while the percentages of other diseases were similar [Alport's syndrome (20%), hypertension (20%) and diabetes (10%)]. Compared to initial DHD heparin requirements (10,111 ± 2219 units), CHD heparin dose requirements (6833 ± 2715 units) were significantly lower (p = 0.045); however, total heparin needs were similar between groups (10,166 ± 4380 units vs. 10,778 ± 2959 units) (p = 0.324). Conclusion: Although patients initiating DHD have greater initial heparin requirements than when on CHD, total heparin doses remain similar to those required on conventional thrice‐weekly hemodialysis. Greater initial heparin doses required during short daily dialysis appear safe compared to those of conventional dialysis.     

The advantages and disadvantages of home hemodialysis

In Australia, 12% of the hemodialysis population dialyze at home. Until recently, the majority of these patients dialyzed for similar hours to those in satellite dialysis. However, in the past 5 years there has been a new departure such that in many centers the concept of home hemodialysis is now synonymous with extended hours dialysis. Registry data supports the concept that increased frequency and duration of dialysis may result in improved patient survival and a reduction in cardiovascular risk profile. It is hoped, therefore, that the long recognized survival benefit observed in home hemodialysis patients may be further augmented by the swing to extended hours dialysis in this patient population. In addition to the physiological benefits of extended hours home dialysis, there are clear quality of life, social, and economic advantages associated with dialyzing at home. There are however a number of perceived disadvantages to home hemodialysis including the application and time commitment required for training, the potential for relationship strain or "burnout," and reluctance to "hospitalize" the home. Overall, however, in this new era of extended hours dialysis, the advantages both physiological and lifestyle of home hemodialysis far outweigh the disadvantages.     

A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease

Home hemodialysis has been a therapeutic option for almost 4 decades. The complexity of dialysis equipment has been a factor-limiting adoption of this modality. We performed a feasibility study to demonstrate the safety of center-based vs. home-based daily hemodialysis with the NxStage System One portable hemodialysis device. We also performed a retrospective analysis to determine if clinical effects previously associated with short-daily dialysis were also seen using this novel device. We conducted a prospective, 2-treatment, 2-period, open-label, crossover study of in-center hemodialysis vs. home hemodialysis in 32 patients treated at 6 U.S. centers. The 8-week In-Center Phase (6 days/week) was followed by a 2-week transition period and then followed by the 8-week Home Phase (6 days/week). We retrospectively collected data on hemodialysis treatment parameters immediately preceding the study in a subset of patients. Twenty-six out of 32 patients (81%) successfully completed the study. Successful delivery of at least 90% of prescribed fluid volume (primary endpoint) was achieved in 98.5% of treatments in-center and 97.3% at home. Total effluent volume as a percentage of prescribed volume was between 94% and 100% for all study weeks. The composite rate of intradialytic and interdialytic adverse events per 100 treatments was significantly higher for the In-Center Phase (5.30) compared with the Home Phase (2.10; p=0.007). Compared with the period immediately preceding the study, there were reductions in blood pressure, antihypertensive medications, and interdialytic weight gain. Daily home hemodialysis with a small, easy-to-use hemodialysis device is a viable dialysis option for end-stage renal disease patients capable of self/partner-administered dialysis.     

The impact of extended-hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access

Few studies adequately document adverse events in patients receiving long, slow, and overnight hemodialysis (NHD). Concerns about high rates of dialysis access complications have been raised. This is an observational cohort study comparing hospital admission rates for vascular access complications between alternate nightly NHD (n=63) and conventional hemodialysis (n=172) patients established on chronic hemodialysis for at least 3 months. Overall, hospital admission rates and hospital admission rates for cardiac and all infective events are also reported. The NHD cohort was younger and less likely to be female, diabetic, or have ischemic heart disease than the conventional hemodialysis cohort. When NHD and buttonhole cannulation technique were used simultaneously, there was a demonstrated increased risk of septic dialysis access events: incidence rate ratio 3.0 (95% confidence interval 1.04-8.66) (P=0.04). The majority of blood culture isolates in NHD patients were gram-positive organisms, particularly Staphylococcus aureus. Alternate nightly NHD did not significantly change total hospital admissions or hospital admissions for indications other than dialysis access complications, compared with conventional hemodialysis. Our data suggest that buttonhole cannulation technique should be used with caution in patients performing extended-hours hemodialysis as this combination appears to increase the risk of septic access complications. Randomized-controlled trials are needed to confirm these findings.     

Symptomatic hyperammonemia after lung transplantation: Lessons learnt

Hyperammonemia, post‐orthotopic lung transplantation, is a rare but mostly fatal complication. Various therapies, including those to decrease ammonia generation, increase nitrogen excretion, and several dialytic methods for removing ammonia have been tried. We describe three lung transplant recipients who developed acute hyperammonemia early after transplantation. Two of the three patients survived after a multidisciplinary approach including discontinuation of drugs, which impair urea cycle, aggressive ammonia reduction with prolonged daily intermittent hemodialysis (HD), and overnight slow low‐efficiency dialysis in conjunction with early weaning of steroids and other therapeutic measures. Our experience suggests that early initiation of dialysis, high dialysis dose, increased frequency, and HD preferably to less efficient modalities increases survival in these patients.     

A Brief History of Daily Hemodialysis

Daily hemodialysis has been in uninterrupted practice since its introduction in California in 1967. Early trials were stopped for technical, logistical, and economical problems, but a rapidly increasing number of centers now perform it on close to 200 patients, either as long nightly or short daytime hemodialysis. Increasing the frequency of dialysis appears much more important in improving patient well-being than increasing the Kt/V dose, and patients quickly experience much more vigor, energy, and improved quality of life when starting daily hemodialysis. Blood pressure improves, and medications can often be discontinued. Similarly, the need for erythropoietin decreases, and nutrition and dry body mass increase. While the cost of dialysis increases, the total cost for a patient decreases as medications and hospitalizations decrease. Technical innovation will solve the logistical problems by letting a machine do the labor necessary to begin and end a dialysis session. Access problems have decreased for native fistula, and the other access types have not been studied enough.     

Why Our Patients Like Daily Hemodialysis

The option of daily hemodialysis (HD) was discussed in November 1998 with a group of 35 HD patients on home or self‐care/limited‐care HD in a single, freestanding unit. After the meeting, 3 patients on home HD chose to switch to daily HD. The clinical success of the first patient and the immediate followers was one of the main reasons for further extension of this experience. At the time of this writing (February 2000), 10 patients were on a daily HD program (8 at home and 2 in a self‐care/limited‐care center) and one was in training for home daily HD. One further patient who tried 1 month of daily HD dropped out for logistic reasons. On daily HD, patients are dialyzed 2 – 3 hours/day, 6 days/ week, with blood flow of 270 – 300 mL/min, on bicarbonate dialysate with individually determined levels of Na and K. The schedule is flexible and a switch to 3 – 4 dialyses/week is occasionally allowed for working needs or for vacation. In addition to the well‐known clinical advantages (better well‐being, blood pressure control, nutrition, etc.), some patients preferred daily HD because of easier organization of daily activities, including work schedule. Patients initially feared frequent needle punctures and excessive burden on partners, but those concerns proved to be less a problem than anticipated. All current patients are willing to continue daily HD; only a nursing shortage limits further extension of the program in the self‐care/limited‐care center.     

Changes in hemoglobin and albumin concentration during nocturnal home hemodialysis

The hemoglobin (Hb) and the serum albumin (S.Alb) concentration commonly rise during seated, conventional thrice-weekly 4 to 4.5 hr hemodialysis (CHD) as a result of rapid fluid removal from the intravascular compartment. Conversely, in long, slow, recumbent nocturnal home hemodialysis (NHHD), the intra-dialytic S.Alb concentration has been shown to fall. In normal human physiology, plasma volume expansion rapidly follows recumbency and is sustained until a resumption of an upright position re-induces plasma volume contraction. The plasma protein dilution of recumbency has been suggested as the mechanism behind this finding in NHHD. Our retrospective analysis of 585 consecutive measurements of predialysis and postdialysis S.Alb and Hb taken from 71 NHHD patients confirmed an intra-dialytic fall in S.Alb (0.99% in alternate night NHHD and 1.4% in 6 nights/week NHHD) compared with an 8.4% rise in a control group of 104 CHD patients (p<0.001). Although the NHHD intra-dialytic Hb rose (3.8% in alternate night NHHD and 2.6% in 6 nights/week NHHD), this rise was significantly greater (8%) in CHD patients (p<0.001), and as physiological data confirm that recumbent dilution for albumin is greater than that for Hb, this may provide the explanation. We conclude that NHHD provides a more physiological volume milieu with the normal physiological dilution mechanisms of recumbency still operating despite the slow, steady volume reduction that accompanied longer hour and more frequent dialysis. These mechanisms are subverted, however, in CHD by the more-aggressive plasma contraction needed to attain adequate control of the intravascular volume in the face of shorter hour, less-frequent dialysis.