Complications of home hemodialysis

Home hemodialysis is regaining popularity as a treatment choice for end-stage kidney disease. This trend is fueled by numerous reports of better survival and improved quality of life with primarily home-based more frequent and/or longer hours of hemodialysis. Home hemodialysis in the contemporary era is generally very safe. Advances in machine technology have reduced technical complications and longer and more frequent treatments have reduced the risk of hypotension and cardiovascular instability. A successful home hemodialysis program must focus on patient safety to prevent serious hemorrhage from needle dislodgement and enable an aseptic cannulation technique. In addition, vigilance in relation to machine maintenance procedures and attention to water quality are key skills that patients must acquire for optimal outcomes. The possibility of increased septic events with longer and more frequent hemodialysis regimens performed in the home, the long-term psychosocial effects of home hemodialysis, and the best methods for maintaining compliance of patients in the long term are of particular contemporary interest.     

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.     

Gustatory sweating recurring on peritoneal dialysis but resolving during periods of hemodialysis

Gustatory sweating is a rare disorder characterized by profuse sweating on the forehead, face, scalp, and neck occurring soon after ingesting food, which has been reported in diabetic patients. The mechanism is thought to be triggered by taste buds and not gastric stimulation. We report a case where gustatory sweating repeatedly developed on peritoneal dialysis that resolved on periods of hemodialysis. A 32-year-old woman with diabetic end-stage renal disease developed gustatory sweating shortly after beginning continuous ambulatory peritoneal dialysis despite excellent clearances. After 5 months, she changed to hemodialysis for 2 months and noticed complete resolution of her gustatory sweating; however, after her return to peritoneal dialysis 2 months later, her gustatory sweating recurred. While on peritoneal dialysis, she was treated with clonidine, which resulted in improvement but not resolution of her symptoms as had occurred on hemodialysis. Another period on hemodialysis resulted in the resolution of her symptoms that returned again after restarting peritoneal dialysis. Clonidine provided incomplete relief while topical glycopyrrolate was effective and without complications. We report recurrent gustatory sweating on peritoneal dialysis that resolved with hemodialysis. We have no data to suggest that intra-abdominal stimulation played a role, but rather that despite excellent clearances neuropathy may have played a role. Treatment with topical glycopyrrolate may be safe and effective given every third day if clonidine is ineffective.     

Survival with short‐daily hemodialysis: Association of time,site, and dose of dialysis

In thrice‐weekly hemodialysis, survival correlates with the length of time (t) of each dialysis and the dose (Kt/V), and deaths occur most frequently on Mondays and Tuesdays. We studied the influence of t and Kt/V on survival in 262 patients on short‐daily hemodialysis (SDHD) and also noted death rate by weekday. Contingency tables, Kaplan‐Meier analysis, regression analysis, and stepwise Cox proportional hazard analysis were used to study the associations of clinical variables with survival. Patients had been on SDHD for a mean of 2.1 (range 0.1–11) years. Mean dialysis time was 12.9 ± 2.3 h/wk and mean weekly stdKt/V was 2.7 ± 0.5. Fifty‐two of the patients died (20%) and 8‐year survival was 54 ± 5%. In an analysis of 4 groups by weekly dialysis time, 5‐year survival continuously increased from 45 ± 8% in those dialyzing <12 hours to 100% in those dialyzing >15 hours without any apparent threshold. There was no association between Kt/V and survival. In Cox proportional hazard analysis, 4 factors were independently associated with survival: age in years Hazard Ratio (HR)=1.05, weekly dialysis hours HR=0.84, home dialysis HR=0.50, and secondary renal disease HR=2.30. Unlike conventional HD, no pattern of excessive death occurred early in the week during SDHD. With SDHD, longer time and dialysis at home were independently associated with improved survival, while Kt/V was not. Homedialysis and dialysis 15+ h/wk appear to maximize survival in SDHD.     

A primer for the prescription of short-daily and nocturnal hemodialysis

More frequent and intensive hemodialysis (HD) schedules continue to garner interest internationally. Two dominant regimens have emerged, namely short-daily and nocturnal HD. A growing body of observational data suggests that these regimens allow more rigorous control of biochemical and physical parameters when compared with conventional HD. This review describes the methodology used in providing more frequent or sustained HD both in center and at home, and attempts to provide a physiological rationale for the practices described in the current literature.     

Determinants of training and technique failure in home hemodialysis

Home hemodialysis (HHD) has clinical and economic advantages compared with in‐center conventional hemodialysis. Many health systems wish to broaden the population to which this modality can be successfully offered. However, determinants of successful HHD training and technique survival are unknown. We hypothesize that both medical and social factors play a role when patients fail to successfully adopt HHD. We examined characteristics of consecutive patients who initiated training for HHD between 2003 and 2011. Patients were classified as “failure” if they failed to complete HHD training or experienced technique failure (TF) within the first year of treatment. Remaining patients were classified as “success.” One hundred seventy‐seven patients initiated HHD training. In the “failure” group (n = 32), 24 did not finish training and 8 had TF. In the “success” group (n = 145), 65 (45%) patients remained on NHD, 49 (34%) discontinued HHD because of renal transplantation and 21 (14%) because of death, while only 10 (7%) eventually transferred to another dialysis modality. In a multivariable logistic regression analysis, the strongest predictors of “failure” were end‐stage renal disease because of diabetes (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4–10.3, P = 0.008) and use of rental housing (OR 3.1, 95% CI 1.3–6.0, P = 0.01). Both medical and social factors are associated with failure to adopt HHD. Enhanced supports or a customized education strategy for these vulnerable patients should be considered.     

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.     

Encapsulating peritoneal sclerosis: Importance to the hemodialysis practitioner

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of long-term peritoneal dialysis (PD) therapy. Encapsulating peritoneal sclerosis is characterized by peritoneal membrane inflammation, followed by progressive peritoneal membrane fibrosis and intestinal encapsulation. Clinical manifestations include ascites as well as intermittent and recurrent small bowel obstruction. The prognosis of EPS is poor. The exact cause of EPS remains unknown. While the risk factors for EPS are not well elucidated, EPS is seen with increased frequency after an increased duration of PD therapy. In more than half the patients who develop EPS, the diagnosis is made after transfer to hemodialysis (HD). It is important for the HD practitioner to initiate surveillance in any patient at risk for EPS while maintaining a heightened index of suspicion for EPS in an HD patient with gastrointestinal symptoms and a history of previous PD therapy. Early diagnosis and prompt initiation of treatment is essential. Early in the course of EPS, immunosuppressive therapy remains the mainstay of treatment. Ultimately, parenteral nutritional support may be required along with surgical therapy to relieve intestinal obstruction. We report a case of EPS in an HD patient at our center highlighting the incidence, risk factors, and treatment strategies in the context of available evidence.     

The use of vascular access audit and infections in home hemodialysis

Vascular access‐related infection is an important adverse event in home hemodialysis (HHD). We hypothesize that errors in self‐cannulation or manipulation of dialysis vascular access are associated with increased incidence of access‐related infection. We conducted a retrospective cohort study of all prevalent HHD patients at the University Health Network. All vascular access‐related infections were recorded from 2006 to 2013. Errors in dialysis access were ascertained by nurse‐administered vascular access checklist. Ninety‐two patients had completed at least one vascular access audit. Median HHD vintage was 2.3 (0.9–5.0) years in patients with appropriate vascular access technique and 5.8 (1.5–9.4) years in patients with erroneous vascular access technique. The overall rate of infection between patients with and without appropriate vascular access technique was similar (0.27 and 0.28 infections per year, P = 0.166). Among patients who were identified with errors in dialysis access manipulation, patients with five or more errors were associated with higher rate of access‐related infection (mean of 0.47 vs. 0.16 infection per patient‐year, P < 0.001). The use of vascular access audit is a feasible strategy, which can identify errors in vascular access technique. Patients with a longer median HHD vintage are associated with higher risk of inappropriate vascular access technique. Patients with multiple errors in vascular access technique are associated with a higher risk of dialysis access‐related infection. Prospective evaluation of the impact of vascular access audit on adverse vascular access events is warranted.     

Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate,clinical, and laboratory outcomes: A 1‐year retrospective observation study

Introduction: While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed. Methods: A 1‐year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin). Findings: NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age‐adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77–20.99, P = 0.04). They consumed less aluminum‐based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol²/L², P < 0.01), with similar hemoglobin levels. Discussion: NHHD appeared to offer higher employment rate, lower dosage of aluminum‐based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong.     

Clinical benefits of ultrapure dialysis fluid for hemodialysis

Ultrapure dialysis fluid contains less than 0.1 CFU/mL and 0.03 EU/mL and can be prepared by ultrafiltration of standard‐quality dialysis fluid. Today, the use of ultrapure dialysis fluid is widely recommended based on our awareness of potential transfer of bacterial products across dialysis membranes. Early observations associated improved fluid quality with reduced incidence of the carpal tunnel syndrome, but provided no proof of mechanism. Recent clinical studies in hemodialysis patients have shown that the introduction of ultrapure dialysis fluid brings about significant improvements in a number of inflammation‐related parameters. Levels of C‐reactive protein and IL‐6 are reduced, anemia management is achieved using less EPO or reaching higher hemoglobin levels, nutritional indices are improved, and β₂‐microglobulin levels have been observed to decline, when ultrapure dialysis fluid is used in comparison with standard‐quality fluid. In addition, some studies have documented reduced levels of advanced glycation end products and delayed decline of residual renal function in patients using ultrapure dialysis fluid. Although further evidence is needed before we can assess the long‐term benefits associated with improved fluid quality, there should be sufficient data available today to support our efforts toward gradual improvement of the microbiological quality of dialysis fluid.     

Left ventricular assist device patient maintained on home hemodialysis: A novel class of patients to the home dialysis population

Severe heart failure is increasingly being managed by cardiac transplantation, and in some cases mechanical support devices serve as destination therapies. Left ventricular assist devices (LVADs) were approved for destination therapy for end stage heart failure patients before the more advanced total artificial heart modality became available. One common complication of mechanical assist device placement is acute kidney injury. Historically, patients with mechanical support devices have had to have inpatient hemodialysis until combined heart kidney transplant. Though, some units have started accepting LVAD patients in outpatient dialysis clinics. The cost of in center hemodialysis remains high and home dialysis modalities are becoming increasingly popular. We report the first patient with an LVAD to undergo training and successful home hemodialysis while awaiting combined heart kidney transplantation.     

Catheter‐related bacteremia and mortality in frequent nocturnal home hemodialysis

Frequent nightly home hemodialysis (NHHD) has emerged as an attractive alternative to thrice weekly in‐center hemodialysis, albeit with preponderant long‐term hemodialysis catheter used. Sixty‐three NHHD patients from University of Virginia Lynchburg Dialysis Facility were matched 1:2 with 121 conventional hemodialysis patients admitted to Fresenius Medical Care North America facilities from January 1, 2007 to December 31, 2010. Matching considered age (± 5 years), gender, race, dialysis vintage, and diabetes. The primary end‐point was the combined incidence of bacteremia/sepsis, for up to 20 months or upon changing to a fistula/graft (with catheter removal), transferring to peritoneal dialysis (PD), or at the time of kidney transplant or death. No significant differences were observed in rate of fistula/graft conversion, transfer to PD, transplant, or death between NHHD and in‐center hemodialysis (IHD) groups. For the first catheter used, the rate of catheter‐related sepsis was not significantly different between the NHHD (1.77 per 100 patient months) and IHD (2.03 per 100 patient months; P = 0.21). Combining all catheters, the rate of bacteremia/sepsis per 100 patient months in the NHHD group was 1.51 and in the IHD group was 2.01 (P = 0.35). Median catheter lifespan for the first catheter was 5.6 (1.7～19.0) for NHHD and 4.6 (2.7～7.8) for the IHD group (P = 0.64), and for all catheters used was 5.2 (Q1～Q3 = 1.5～15.2) months in NHHD group, and 4.1 (2.0～6.8) months in IHD group (P = 0.20). The rate of bacteremia and death is not different for up to 20 months in catheter users who dialyze via frequent NHHD vs. thrice weekly IHD.     

The renaissance of home hemodialysis: where we are, why we got here, what is happening in the United States and elsewhere

Home hemodialysis has been around since 1964, but its use has declined over the years in most countries, this despite its advantages, particularly improved patient survival and quality of life and significant cost savings. Experience has shown that home hemodialysis can be performed successfully by many more patients than at present. Recently, with the demonstration of even better results with more frequent hemodialysis that is obviously best performed at home and with the development of new, more patient-friendly machines, the use of home hemodialysis is beginning to increase again.