Nocturnal Home Haemodialysis
A Brief Overview
Comparison with conventional haemodialysis
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Introduction
This overview:
First it reviews conventional haemodialysis (CHD)
Then it asks ‘can dialysis be made better?’
And finally it introduces nocturnal haemodialysis (NHHD)
Its’ benefits
Its’ risks
And …who might be suitable
And …
If after reading this section, you think NHHD might be for you, it concludes by recommending you take in the full experience of "A Comprehensive Look at Nocturnal Home Dialysis"
Conventional haemodialysis … here-after called ‘CHD’
CHD has traditionally been a day-time treatment
CHD is often poorly tolerated and can cause many unpleasant symptoms
CHD has poor outcomes for many patients
CHD uses methods for improving the ‘adequacy’ of dialysis which focus on increasing treatment ‘aggressiveness’ rather than trying to make it more gentle
Additionally…
CHD is usually given for 3 sessions/week, commonly for ~4 hrs/session and always as a daytime, ‘awake’ treatment
CHD must try to remove all the waste and fluid retained by the body over the 2-3 days since the previous treatment, yet must do this in the short space of ~4-4.5 hrs (or, in the US, often significantly less? In the US, mean dialysis sessional time is ~210 minutes … this compares to ~270 minutes in Australia and commonly ~300 minutes in Japan.
Rapid waste and fluid removal rate, as is implicit in CHD, can lead to many symptoms … cramp, nausea, vomiting, a falling blood pressure, fainting and after-treatment exhaustion.
Can dialysis be made better?
Dialysis can only be made more gentle and more tolerable by:
1. Significantly increasing the length of each treatment time
2. Increasing the number of treatments per week
or … even better …
3. By increasing both!
This can only be possible, in a practical and acceptable way that maintains lifestyle, if dialysis can be performed during sleep.
Few, if any, will or should be asked to accept longer and more frequent dialysis sessions during the day … at least in excess of 5 hours/session (as in Japan).
Recent thinking has challenged traditional facility-based CHD practices and NOCTURNAL HOME HAEMODIALYSIS has emerged as an obvious solution.
Nocturnal home haemodialysis … here-after called ‘NHHD’
NHHD is long, slow, gentle and generally self-performed dialysis
NHHD is undertaken, usually at home, after a quiet dialysis machine has been installed in the bedroom
NHHD can be provided in ‘sleep-over’ centres in some countries and states – though this is not as ideal as home-based care as, usually, centre-delivered NHHD is limited in its frequency if not in its hours
NHHD can be performed in frequency anywhere from every alternate night through to 6 or 7 nights per week – again, especially in the home
NHHD delivers up to 4 times the amount of dialysis (8-9 hrs/treatment, 6-7 nights/week = 50-60 hrs/week compared to ~12 hrs/week for CHD)
The benefits of NHHD include:
No more of the usual side-effects of CHD
No more ‘crashes’ from falling blood pressure
Minimal (alternate nights) or no (5-6 nights/wk) fluid or dietary restrictions
No need for phosphate binding medicines if ~4-5 sessions or more are given per week
No need for BP medication for most patients
No need for a dialysis partner (see below) – solo, home, overnight dialysis is not only possible but is practical in un-partnered people.
NOTE:
The acceptance of unpartnered home haemodialysis remains controversial
The availability of unpartnered NHHD may be subject to local conditions and practices.
Further benefits include:
Stress on the heart is diminished
Calcium deposits in blood vessels regress
Sleep patterns normalize to generally refreshing rest
Sleep apnoea improves or resolves
Thinking clears and memory improves
Sexual drive/function improves
And … as the biggest benefits of all:
Day-time and waking hours are given back
Day-time activities return to normal without dialysis interference
Energy to work and work capacity is restored
Employment opportunity is again equal with people not on dialysis
Independence and self-esteem is restored
Potential risks include, but are yet to demonstrate:
1. ‘Over-dialysis’ – the inadvertent removal of essential substances, vitamins and minerals by prolonged filtration
There is no evidence that this is occurs
2. Access disconnection or infection
See discussion later on in the detailed NHHD section
3. Blood or fluid loss whilst asleep
See discussion later on in the detailed NHHD section
4. Heparin-related osteoporosis
There is no evidence that this is occurs
5. Technique ‘burn-out’
In our experience, this is more often an issue of ‘partner burn- out’ when the partner is trained as the dialysis ‘carer’ and thus must take responsibility for the dialysis as well as for most other family tasks. It is not our practice to train the partner as ‘carer’ but to always train the patient to self and sole care. It is of note that NHHD drop-out rates are far higher in the US which requires (carer-led NHHD) than in Australia which encourages patient self-care NHHD.
Who is suitable for NHHD?
All CHD patients (3 x 4 hrs/week) who are already at home … this rarely applies to US patients but commonly does to non-US-based patients where home dialysis has been usual and normal treatment but where, till recently, the home program has predominantly been a home-based conventional dialysis 3x4 daytime regime.
Many satellite or limited care CHD patients
As dialysis partners are not necessary (see comments in section above), solo CHD patients without partners can be considered in some places. Local legality and other factors currently influence and limit this potential
AV fistula, graft and catheter access patients
People with ‘sick hearts’ will, at least potentially, do far better with longer, more frequent and gentler dialysis and should be considered
About 1/3rd of all CHD patients are, in my view, likely suitable
Where possible, all/any patients who are suitable for home dialysis should be identified during pre-dialysis education and preparation. Home therapies should be openly discussed with them as the best possible option and, if suited, they should then be trained directly into NHHD without ever experiencing the personal and emotional confinement of the dialysis unit.
If this brief overview interests you, I strongly recommend you move on to read "A Comprehensive Look at Nocturnal Home Dialysis". This section discusses:
How dialysis got to where it is now
The differences between CHD and NHHD
The details of NHHD and how it is safe to do at home
Our program in Geelong – a real outcomes study
Authored by Prof John Agar. Copyright © 2012
Nocturnal Haemodialysis Program, Barwon Health.
All rights reserved. Revised: July 1st 2012