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.     

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.     

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.     

Home hemodialysis in Australia and New Zealand: practical problems and solutions

Home hemodialysis, as practiced in Australia and New Zealand, offers patients the return of self-control and self-esteem. It also allows reconnection with family, friends and (re)employment. Though there are emotional and time-related "costs" with home hemodialysis, these center on training time, commitment and patient or family stresses and, if carefully managed and properly resourced, can be overcome for most home-suitable patients. As we believe many center-based hemodialysis patients are home-suitable and that home care is severely under-utilized, assessment techniques to maximize uptake are examined. While patient dropout from home care relates more to staff attitudes than to true home-failure, dropout is minimized by ensuring the patient and not a carer takes full dialysis responsibility with the carer acting as a supporter and not the facilitator. Installation of home equipment is simple and cheap, the financial costs of home hemodialysis being substantially less than those of facility care where salary and infrastructure costs far exceed training, equipment, installation and maintenance costs at home. Home monitoring is not routinely required especially with longer, more frequent regimens-but effective 24-hour on-call nurse and technician cover is essential. Intravenous drug self-administration at home is safe and effective, reducing the need for hospital visits to a 2-3 monthly minimum. The debilitating effects of facility care cannot be over-emphasized while the liberating psychology of a well-supported hemodialysis program is truly satisfying for patient and staff alike.     

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.     

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.     

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.     

We Should Strive for Optimal Hemodialysis: A Criticism of the Hemodialysis Adequacy Concept

Adequacy of hemodialysis is frequently equated with Kt/V_urea , the amount of urea clearance (K) multiplied by time (t) and divided by urea distribution volume (V). Several formulas have been developed to calculate Kt/V_urea from the pre‐ and post‐dialysis urea concentrations. In three‐times‐weekly hemodialysis, a single pool (spKt/V_urea) value of 1.3 per treatment is commonly considered to indicate adequate therapy.
Despite providing the recommended spKt/V_urea of 1.3 per treatment, short dialysis with rapid ultrafiltration is associated with multiple intradialytic and interdialytic complications. Patients experience cramps, nausea, vomiting, headaches, fatigue, hypotensive episodes during dialysis, and hangover after dialysis; patients remain fluid overloaded with subsequent poor blood pressure control, left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality.
According to Webster's dictionary, "optimal" means most desirable or satisfactory; "adequate" means sufficient for a specific requirement or barely sufficient or satisfactory. Optimal dialysis is the method of dialysis yielding results that cannot be further improved. New approaches, including hemeral quotidian or long nocturnal dialysis, provide opportunities to abandon the notion that adequate dialysis is "good enough" for our patients. Optimal dialysis should be our goal. Dialysis sessions should be long and frequent enough to provide excellent intra‐ and interdialytic tolerance of hemodialysis, normalization of serum calcium and phosphorus, blood pressure control, normal myocardial morphology and function, and hormonal balance, and to eliminate all, even subtle, uremic symptoms.     

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.     

Impact of Predialysis Care on Clinical Outcomes

Introduction: A structured predialysis multidisciplinary team program is beneficial in improving quality of life in patients with end‐stage renal disease (ESRD). Educating pre‐ESRD patients about their disease is vital in their care. Patients who can identify signs and symptoms of impending problems can seek help and avoid complications that may lead to hospital admissions. Our dialysis center offers two predialysis classes in a structured format. The first class is for those patients with mild to moderate renal disease, whereas the second class is for those with advanced renal disease who are expected to need dialysis in 3 to 6 months. The patients are followed by a multidisciplinary team once they are enrolled in our chronic kidney disease program. Methods: We retrospectively reviewed all the charts of patients who started dialysis at our center between 1997 and 2000. We identified 68 patients who participated in the predialysis education program and 35 patients who did not because of late referral or refusal to participate. We compared these two groups over a 100‐day period (10 days before initial dialysis and 90 days after), for hospitalizations, emergency room (ER) visits, and dialysis access placement. Patients' comorbid conditions, complications, and length of hospitalizations were extracted from the medical records. Results: The 68 patients who completed the predialysis program had an average age of 60.3 years, a total of 96 hospital days, and 39 ER visits. Average length of hospital stay for these patients was 1.4 days. Three patients (4.4%) required placement of temporary catheters for the initial dialysis. Fifty‐one percent of these patients had diabetes mellitus. The 35 patients of average age of 54.9 years who did not go through the program had 347 total hospital days and 39 ER visits. Average length of hospitalization was 9.9 days. Thirteen patients (37%) required temporary catheters for initial dialysis. This group included 16 patients (45.7%) with diabetes. Conclusion: Patients who participated in a multidisciplinary predialysis education program had fewer complications, ER visits, and hospitalizations. They also had fewer temporary catheter placements, shorter hospital stays, and reduced costs associated with initial dialysis.     

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.     

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.     

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 economic costs of road traffic crashes: Australia, states and territories

In this paper, we obtain detailed data on road traffic crash (RTC) casualties, by severity, for each of the eight state and territory jurisdictions for Australia and use these to estimate and compare the economic impact of RTCs across these regions. We show that the annual cost of RTCs in Australia, in 2003, was approximately $17b, which is approximately 2.3% of the Gross Domestic Product (GDP). Importantly, though, there is remarkable intra-national variation in the incident rates of RTCs in Australia and costs range from approximately 0.62 to 3.63% of Gross State Product (GSP). The paper makes two fundamental contributions: (i) it provides a detailed breakdown of estimated RTC casualties, by state and territory regions in Australia, and (ii) it presents the first sub-national breakdown of RTC costs for Australia. We trust that these contributions will assist policy-makers to understand sub-national variations in the road toll better and will encourage further research on the causes of the marked differences between RTC outcomes across the states and territories of Australia.     

Results of human factors testing in a novel Hemodialysis system designed for ease of patient use

Introduction Home hemodialysis has not been widely adopted despite superior outcomes relative to conventional in‐center hemodialysis. Patients receiving home hemodialysis experience high rates of technique failure owing to machine complexity, training burden, and the inability to master treatments independently. Methods We conducted human factors testing on 15 health care professionals (HCPs) and 15 patients upon release of the defined training program on the Tablo? Hemodialysis System. Each participant completed one training and one testing session conducted in a simulated clinical environment. Training sessions lasted <3 hours for HCPs and <4 hours for patients, with an hour break between sessions for knowledge decay. During the testing session, we recorded participant behavior and data according to standard performance and safety‐based criteria. Findings Of 15 HCPs, 10 were registered nurses and five patient care technicians, with a broad range of dialysis work experience and no limitations other than visual correction. Of 15 patients (average age 48 years), 13 reported no limitations and two reported modest limitations—partial deafness and blindness in one eye, respectively. The average error rate was 4.4 per session for HCPs and 2.9 per session for patients out of a total possible 1,710 opportunities for errors. Despite having received minimal training, neither HCPs nor patients committed safety‐related errors that required mitigation; rather, we noted only minor errors and operational difficulties. Discussion The Tablo? Hemodialysis System is easy to use, and may help to enable self‐care and home hemodialysis in settings heretofore associated with high rates of technique failure.     

Hemodialysis for infants,children, and adolescents

Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital‐based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.     

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.