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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




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



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Authored by Prof John Agar. Copyright © 2012
Nocturnal Haemodialysis Program, Barwon Health.
All rights reserved. Revised: July 1st 2012