Home and Intensive Hemodialysis

Interest in home hemodialysis (HD) continues to grow. Provider and patient preferences, decreasing costs of equipment and consumables, new funding models, and more user-friendly technology may be facilitating factors. Moreover, the home setting lends itself well to longer and more frequent (collectively, “intensive”) HD sessions than are typically available in-center, though these intensified regimens can be provided in-center as well. It is useful to distinguish between (a) conventional HD (3–5 hours, 3 per week), (b) frequent HD (5–7 per week), which can be frequent short (1.5–3 hours), frequent standard (3–5 hours), or frequent long (>5 hours), or (c) long-session-length regimens (>5 hours) given 3 days per week or every other day. Short and standard frequent HD are typically referred to as “daily HD” (DHD), while long, frequent HD is typically done at night and is called frequent “nocturnal HD” (NHD).

I. MODALITY SELECTION. In the absence of evidence-based practice guidelines addressing modality selection, we propose some general guiding principles: (a) patients approaching renal replacement therapy should receive education regarding all available modality options, including conservative care without dialysis, preemptive transplantation, home HD, peritoneal dialysis (PD), and in-center HD; (b) where medically appropriate and feasible, home modalities (including PD) should be promoted as first-line therapies when transplantation is not imminent; (c) the choice between PD and home HD should be based on patient preference, availability, feasibility, and medical factors (e.g., patients seeking pregnancy should preferentially receive frequent NHD; patients at risk for suboptimal clearance with PD should consider home HD); (d) home HD should be considered following the failure of PD or a renal allograft—this approach requires carefully timed education and planning, but can lead to more patients maintaining their independence from center HD; and (e) more intensified (home or center) HD regimens may be considered to improve extracellular fluid volume (especially in those with high fluid gains), blood pressure (BP), left ventricular (LV) mass, phosphate, and quality of life.

A. Frequent versus conventional HD. Prescription patterns vary geographically, and also according to program and provider preferences. There are no evidence-based guidelines that directly address the choice between conventional and frequent (long or short) HD. In the majority of cases, the treatment schedule will depend on patient preferences (such as convenience and noninterference with work, sleep, and social schedules), as well as clearance and ultrafiltration needs. Starting with one particular regimen does not preclude switching to another at any time, and many patients have used combinations of long and short treatments to accommodate work and other schedules. Where possible, we recommend avoiding a 3-day interdialytic interval, setting a lower boundary of every other day for home HD, though this approach is less likely to be available in-center.

B. Home HD

1. Patient selection. Reported prevalent rates for home HD are generally <5% in most jurisdictions, but as high as 15% in others. The primary prerequisite for home HD is a willing patient or partner who is able to learn to safely perform the dialysis procedure. Uncontrolled seizures, hypoglycemia, noncompliance with medical care, and significant intradialytic hemodynamic instability requiring frequent nursing interventions are relative contraindications. Inability to use heparin precludes long HD with lower blood flow rates (e.g., 150 mL/min), but not prescriptions with higher (e.g., >300 mL/min) blood flow. The presence of multiple or severe comorbidities are not contraindications to home HD, but frailty and inability to perform self-care HD may represent significant barriers if no assistance is available. Home HD programs should develop standardized intake procedures, and criteria for home HD eligibility should include the patient’s or helper’s motor skills, strength, vision, hearing, reading ability, motivation, and adherence. When significant functional barriers are identified, paid caregivers can be considered, if available.

2. Home environment suitability. The home needs to be assessed by a renal technologist, focusing on (a) water quantity and quality, (b) electrical supply, (c) storage space, and (d) cleanliness. These rarely pose insurmountable barriers to home dialysis, though the patient must understand the nature and extent of the changes needed in order to accommodate the necessary equipment. Local building codes should be adhered to, and, occasionally, permission from landlords must be sought prior to beginning any alterations to plumbing and electrical infrastructure.

C. In-center HD. Reasons for choosing in-center over home-based HD include (a) patient safety concerns, (b) vascular access or cannulation problems, (c) patient or partner inability or unwillingness to perform the HD procedure at home, (d) unsuitable home environment (space, electrical, hygiene, or plumbing limitations), and (e) patient preference.

While conventional regimens predominate in-center, intensified center HD is increasingly available, with practices varying by jurisdiction. In Canada, Australia, and Europe, DHD is offered for a wide range of indications, including (a) refractory volume overload, (b) refractory hyperphosphatemia and/or calciphylaxis, (c) failure to thrive, and (d) pregnancy, though evidence to support these indications is limited. In France, long, thrice-weekly, in-center, daytime HD is common, and long, thrice-weekly HD at night is becoming increasingly available in the United States. Long, frequent NHD is not usually done in-center. Transportation, proximity to the treatment center, patient lifestyle, and demands on the patient’s family are important factors that may determine whether in-center intensive HD is considered. In-center intensified regimens also impose increased demands on space, equipment, and nursing and technical support staff. In general, programs require a “critical mass” of patients receiving intensified regimens to maintain a pool of adequately trained staff and to realize economies of scale. Lack of availability of overnight staff and ability to rapidly “turn over” larger numbers of DHD treatments may require alternative staffing models.

II. TECHNICAL CONSIDERATIONS FOR HOME HD

A. Training. The length of the training period depends on the patient’s previous experience with HD. Without prior experience, patients typically require one-on-one training with an experienced nurse for at least 6 weeks to become safe and proficient, while patients previously undergoing self-care HD require less training time. Some programs with long wait times for home HD training offer training in self-care HD units. Educational manuals written in the patient’s language at the appropriate reading and comprehension level are also useful. Many programs require patients to “recertify” annually, by demonstrating in the training unit setting that they are able to correctly perform the dialysis procedure and blood access, and troubleshoot effectively.

B. Vascular access. The Canadian Society of Nephrology (CSN) guidelines for the management of patients with ESRD (end-stage renal disease) treated with intensive HD (Nesrallah, 2013) recommend arteriovenous (AV) fistulae and grafts over catheters, because of lower infection risk (conditional/weak recommendation, very low quality evidence), but acknowledge that the technical demands of cannulation may represent a barrier to home HD for some patients.

In patients with AV fistulae, the “buttonhole” technique, which involves recannulation of precisely the same two (or two pairs of) sites with blunt needles, has been popular as it may be easier to learn than the standard, “rope-ladder” (rotating site), method (see Chapter 6). However, buttonhole cannulation may result in higher rates of Staphylococcus aureus bacteremia (Muir, 2014), and as such, the CSN guidelines recommend using the buttonhole method in conjunction with topical antimicrobial prophylaxis with mupirocin (conditional/weak recommendation, very low quality evidence) (Nesrallah, 2010, 2013). With synthetic grafts, needle sites are rotated in the usual fashion. Low blood flows of 200–250 mL/min and single needle are sufficient for NHD, where high dialysis efficiency is not required.

C. Dialysis membranes. Currently, there are no data to support the use of one kind of dialysis membrane over another in home HD. In recent years, most centers have reported using high-flux dialyzers. Low dialyzer surface area can be acceptable for long HD (Pierratos, 1999). Dialyzer reuse has been described in home dialysis (Pierratos, 2000) but has largely been abandoned with the fall in prices of dialysis membranes.

D. Patient safety and precautions. Appropriate patient selection, training, and ongoing supervision are of utmost importance to ensure patient safety at home. The dialysis machine screen should be easily visible at all times, from whichever position the patient dialyzes, and the controls should be easily accessible. Some additional precautions include the following:

1. Alarms and communication. The patient (or caregiver) must be able to hear the dialysis machine and its alarms and be trained on how to respond to them. Patients must have a telephone within hand-reaching distance of the dialysis machine to contact emergency services, if needed. Some programs prefer a wired (noncordless) landline telephone over a cellular phone, to ensure function during power failure or inadequate network reception. The telephone ringer must be audible by the patient in case of contact attempts by a remote monitoring center.

2. Prevention of line disconnection

a. Proper cannulation technique. Patient or caregiver competence with the cannulation procedure and with securing the cannula are mandatory prerequisites for home treatment.

b. Securing lines. Meticulous taping of the blood tubing connection to the dialysis catheter is very important to prevent exsanguination from accidental disconnection. Plastic clamshell locking boxes have been used to prevent catheter–tubing separation (Pierratos, 1999). A small blood line connector clip (HemaSafe, Fresenius NA, Lexington, MA) is widely available.

3. Prevention of morbidity when lines disconnect

a. Closed connector devices. The use of a closed connector device is recommended if the patient performs dialysis while asleep (conditional/weak recommendation, very low quality evidence) (Nesrallah, 2013) to prevent air embolization and bleeding resulting from accidental disconnection of the tubing from the dialysis catheter. These are catheter caps with a slit diaphragm, allowing blood flow while in place. They are replaced periodically from every week to every month depending on local practices and manufacturer recommendations. The InterLink System (Becton Dickinson, Franklin Lakes, NJ) can be used only for long HD, as it results in increased arterial and venous pressures at the higher pump speeds used in other regimens. The TEGO (ICU Medical, CA) connector provides less resistance to flow and can be used with higher blood flow rates. The Swan-Lock connector (Codan, Lensahn, Germany) has also been used.

b. Moisture detectors. An enuresis alarm, such as the Drisleeper (Alpha Consultants Ltd., Nelson, New Zealand), can be attached to the cannula entry points to detect bleeding. Disposable leak detectors are also available (RedSense Medical AB, Halmstad, Sweden). A wireless wetness detector, which stops the machine blood pump, was recently released (Fresenius Medical Care, Lexington, MA). Finally, moisture sensors can be placed on the floor around the machine and near the water supply to detect blood, dialysate, and water leaks (Pierratos, 2000).

c. Two-pump, single-needle system. In case of accidental disconnection of the venous line, substantial blood loss and even exsanguination can occur. As discussed in Chapter 4, one cannot rely on a drop in the venous line pressure after line disconnection to stop the blood pump, and the technology described above must be relied upon. Single-needle dialysis reduces the risk of bleeding due to line disconnection, as bleeding will then be restricted to flow from the fistula or catheter, rather than via the blood pump. For this reason, single-needle dialysis is likely to be a safer option for frequent NHD performed at home. Given the length and frequency of sessions with long HD, the slightly reduced clearance associated with single-needle HD is not a major concern.

4. Monitoring. Monitoring is typically only considered for NHD. A modem or high-speed Internet connection of the HD machine to specialized equipment can allow for software-based real-time monitoring to detect technical problems and alarms as they arise (e.g., air and blood leaks). Monitoring is also a useful means by which to track treatment adherence. Rarely are patient data such as BP monitored during night-time dialysis; thus, while monitoring provides patient reassurance and security, it is unclear whether monitoring actually prevents catastrophic events. Some jurisdictions require live remote monitoring by law (e.g., New York), but most programs use it for home NHD for the first 3 months (Heidenheim, 2003); some programs do not use it at all (Humber River Hospital, Toronto). iCare (Fresenius Medical Care, Lexington, MA) is one such commercially available real-time monitoring system. Automated telephone response systems have also been used with variable success.

III. INFRASTRUCTURE REQUIREMENTS FOR HOME HD

A. Support staff. Specially trained nurses, biomedical technicians, and physicians are required. Nurses are required for assessment and training, telephone follow-up and troubleshooting, ordering of patient supplies, and home visits, while technicians provide machine maintenance and monitor water quality. Biomedical engineering personnel should be involved in the development of local policies governing practices, standards, and protocols for the installation and maintenance of equipment. The dialysis program’s payment carrier should be informed of any changes to services provided.

B. Space. Adequate clinic space with appropriate plumbing is needed to allow patient training, patient assessments, and follow-up clinic visits with the physician and allied health personnel.

C. Water supply. Water quality should be assessed regardless of the source. Endotoxins, mineral content, and chloramines should be quantified. Rural water supplies must also be tested for coliform bacteria. International standards exist for water purity (see Chapter 5) and should be followed. Water purification system and HD equipment manufacturers typically specify water pressure requirements.

1. Water purification.

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