Nocturnal Haemodialysis
How, when and where NHHD began
Nocturnal Home HaemoDialysis (NHHD) – as we currently know it – first began in Toronto, Canada in 1993 when Dr Uldall and Dr Pierratos from Toronto took the 3 nights/wk, clinic-based overnight dialysis program that Dr Charra had been using in Tassin, France, and converted it to a 6nights/wk, overnight home-based nocturnal HD treatment.
NHHD programs can now be found in North America, Europe, Australia and New Zealand, throughout Europe with a fast-growing programs in Finland, Hong Kong, Turkey and now India.
Though there are now some facilities offering ‘sleep-over’ nocturnal haemodialysis (NHD) in the US and Australia, home remains the commonest site for these nocturnal programs and I will therefore use the term NHHD throughout.
NHHD can be done from 3 nights/wk to every night
I personally believe that more dialysis is better dialysis
I therefore recommend a 5-6 night/wk program for most of our patients though some do the minimum of alternate night NHHD and a few do 4 nights/week. The mean dialysis frequency in our 30 patient program is 5.2 nights/week
‘Wellness’ seems to increase with the number of dialysis hours - the more, the better
The most common options are:
‘Full’ NHHD = 5-6 nights/wk with 1-2 ‘rest’ nights/week
= the program encouraged by ourselves in Geelong, the Toronto team of Dr Pierratos and the Lynchburg WA group led by Dr Robert Lockridge
Alternate nightly NHHD – 3.5 nights/week
= the program adopted across most other Australian services
NHHD has many advantages over ‘conventional’ 4x3 HD …
First, NHHD provides 50-60 hrs dialysis/wk … depending on the number of hours/night (8 or 9) and the number of nights/wk (6 or 7)
‘Conventional’ 4x3 HD provides ~12hrs/wk, depending on dialysis staff rosters and schedules
Most importantly, all dialysis-related symptoms (cramp, vomiting and ‘flats’) simply disappear on NHHD
1. Low blood pressure problems disappear
Understanding how and why low blood pressure ‘crashes’ or ‘flats’ are abolished is the key to understanding ...
How it is safe to dialyse through the night while asleep
How it can be safe to dialyse without a partner
see DIALYSIS ISSUES
2. Other dialysis-related symptoms disappear
This includes:
Dialysis-induced cramps
Post-HD headache and dizziness
Post HD weakness and exhaustion
Nausea and vomiting and thirst
3. Diet restrictions and complex medication are over
There is no need for dietary potassium restriction. Bananas and citrus fruits … all the ‘denied’ and ‘forbidden’ … are back on the menu
There are no fluid restrictions in 6 night/wk NHHD
Blood pressure pills are stopped in most patients
Phosphate binding medications stop at the outset
Nutrition improves as dietary restrictions are lifted
This leads to better blood albumin level
4. The circulation is the big winner
The thickness of the muscle wall of the left ventricle normalizes as the strain is lifted from the heart
Calcium deposits in blood vessel walls diminish
Sleep patterns return to normal … at first this seems impossible and you are right to feel skeptical but … after the first month on NHHD during which adjustment to the different noises and sounds is needed, patients report not only sound sleep but improved quality of sleep such that they wake refreshed …something many conventional HD patients never do
Snoring and sleep apnoea lessen or disappear
Thinking clears and memory function improves
Sexual drive, function and erection quality in men improve
5. Of all benefits, the most compelling are…
Daylight, waking-hour freedom is returned for leisure, family and the chance to work
A return to part or full-time work boosts self-esteem and confidence
Imagine the feeling, switching from dependence on social security to self-dependence
Can there be too much dialysis?
Normal kidneys don’t just filter. They also reclaim important substances which are inadvertently filtered along with the waste
Dialysers aren’t quite so clever! Important substances may be filtered by the dialyser but then lost. Unlike normal kidneys, dialysers lack a mechanism to reclaim these inadvertently filtered substances … like water soluble vitamins
‘Depletion syndromes’ are thus possible for substances like:
Trace elements
Potassium, phosphate and magnesium
Water soluble vitamins – especially B and C group vitamins … we replace these in our dialysis patients with a vitamin supplement
Folic Acid … we similarly replace folic acid
Importantly, no depletion syndromes or conditions have yet been encountered
Other risks of NHHD …
1. The risk that the blood access (fistula or catheter) might disconnect and lead to blood loss during asleep is a powerful concern in patients considering NHHD … but, there are ways to protect against this.
see SAFETY ON NHHD
2. The risk of infection – with a blood infection arising from infection of the AV fistula or access catheter is another concern.
Though there is no reported evidence to date that there is a greater risk of access-related infection in NHHD patients compared to conventional HD patients, we have had some concerns in this area and wonder if this is a feature of under-reporting of this complication.
We have encountered several episodes of fistula-related sepsis at a rate we believe is higher than that seen in our conventional native AVF dialysis patients though it is lower than the reported rate of infection in catheter-access patients world-wide. The risk rate seems to lie somewhere in between.
We have reported this in the Australian literature and I will detail our experience to date in the section Geelong Experience.
This concern does not alter our conviction and commitment to NHHD but is an problem which needs careful consideration.
We believe that strict adherence to protocols of needle insertion and stabilization are of paramount importance as our analysis of our experience has shown us that infection only occurs at a higher than expected rate for native AVF in general if the patient technique varies from what was taught to them ... i.e. do not cut corners in needling technique!
The use of mupirocin ointment or, in our hands, MediHoneyÔ to the puncture site after needle removal may also be a useful adjunct to current protocols.
see SAFETY ON NHHD
Might access damage occur from more needling?
There has been no evidence that this occurs
We use the buttonhole technique to minimise trauma
Might increased heparin use cause bone damage?
Repeated heparin use may contribute to osteoporosis
Careful study has not shown this over > 9 years
Might ‘burn-out’ or relationship issues arise?
This is my greatest anxiety for NHHD patients
It is the least ‘predictable/preventable’ consequence
We believe that burn-out is as much (or more) a feature of carers than of the patients themselves … and as, in Australia, we do not routinely train a caregiver, it is a problem we have not encountered as much as is reportedly the case in the US
For this risk, I think it is … ‘watch this space’
Who might be suitable for NHHD?
Any and all home haemodialysis patients
Many satellite/limited care haemodialysis patients
Dialysis partners are not needed – at least this is true in Australia
Low blood pressure is abolished
Catheter or AVF access is suitable
Buttonhole technique preferred … though some of our colleagues would dispute this and feel that the ladder technique of needle insertion is preferable. I think the jury is still out on this point.
People with ‘sick hearts’ do very well
This is due to better blood volume control in this group
As a result, selected in-centre patients are also suitable
I believe 30-40% of all HD patients could do NHHD
NHHD patients report:
Feeling healthier and hungrier
Feeling more alert and ‘in control’
Feeling no symptoms of fluid accumulation
An improvement in libido (sexual drive and capacity)
Restful sleep … waking without a ‘hangover’
Sleep studies show sleep apnoea is corrected by NHHD
Oddly, periodic limb movements (restless legs) do not diminish
Welcoming the withdrawal of blood pressure and binder medications
There are added costs…
6-7 nights/wk NHHD clearly doubles the cost of ‘consumables’ (lines, dialysers, on/off packs, fistula needles etc
Capital costs rise (there must be one machine/patient)
But, like leasing a car, this is not an enormous expense if ‘amortized’ over the 10 year expected lifespan of a machine
Installation costs are incurred (~A$3000/patient) – in Australia this is funded by the renal service and not the patient
Computing, modem, internet costs are an issue if remote monitoring is used – though not many are continuing to use modem monitoring
Training and maintenance costs increase
On-call costs must be met for nurses and/or technicians
But, there are savings too …
Hospital bed days fall significantly
Drug costs are reduced
BP medications and phosphate binders cease and EPO costs fall
In all reports, there is a significant return to employment
Major savings in reduced nursing and infrastructure costs allow scarce nursing resources to be redirected to the care of the more severely ill
Redirection of building and utility resources to areas of need
Summary
We believe nocturnal haemodialysis …
Is viable, safe, well accepted and effective
Is suitable for both partnered & single patients
Offers significant improvement in:
Life-style, rehabilitation and work capacity
Biochemical stability and normality
Dietary and fluid freedom
Subjective and restorative sleep
Offers a new dialysis choice and enhances self-determination
In addition …
Flexibility of choice should and must replace the institutionalized one-size-fits-all approaches of the past
Time and frequency must be the prime determinants of adequacy
New emerging technologies that help attain these goals must be embraced
The Geelong experience
To see the results of our program to, I suggest you visit the following link for 1st hand information.
Our Geelong program is small compared with those in Toronto and London (Canada) and Lynchburg (WV) but …
We are proud of our efforts/results
We present our data (so far) to help you see how NHHD ‘works’ within a real program
But … our longer-term dream is to create and then ‘marry’:
Flexible therapies based on blends of increased time and frequency (as this website has described)
With …
Newer machines/technology (now emerging) that will provide:
Closed hot-water or other method sterilising systems
Internalization of lines and dialyser, changed fortnightly or monthly
Simplified ‘on-off’ procedures which reduce the ‘on’ and ‘off’ times to only a few minutes each
Purpose-designed machines for nightly (or daily) therapy
And … that dream is now a slowly emerging reality
Finally then …
If you have stuck the distance to this point, you clearly are …
Resilient by nature
Interested in the concepts I have advanced in this website
A potential self-advocate to improve your dialysis outcomes
If what I have discussed herein makes sense to you, talk with your managing renal team
See if they can help you further
Encourage them to look beyond the bends to the straight beyond
Ensure that they research the financial benefits which accrue to renal services through NHHD
There are several papers in the literature which discuss the financial benefits to renal services which accrue from the reductions in nursing and infrastructure costs
Our own simple analysis is given in an original paper in Haemodialysis International: 7(4), 1-12: 2003, while a more detailed paper is in preparation
It is important to note that dialysis demand is 'exploding' as the impact of diabetic renal disease is now being felt everywhere … cost containment is thus not only prudent but essential if services are to be maintained
In the end, NHHD is not difficult to afford, set up and administer – it is simply a change in mind-set … though sometimes that can be the most difficult hurdle of all
And … to finish with a special thought
Good dialysis is like good lovemaking
The longer, the better
The slower, the better
The gentler, the better
The more frequent, the better
Authored by Prof John Agar. Copyright © 2012
Nocturnal Haemodialysis Program, Barwon Health.
All rights reserved. Revised: July 1st 2012