American Journal of Kidney Diseases
Volume 54, Issue 6 , Pages 1171-1184, December 2009

Home Hemodialysis, Daily Hemodialysis, and Nocturnal Hemodialysis: Core Curriculum 2009

  • Jeffrey Perl, MD, FRCP(C)
    • ,
  • Christopher T. Chan, MD, FRCP(C)

      Affiliations

    • Corresponding Author InformationAddress correspondence to Christopher T. Chan, MD, FRCP(C), Toronto General Hospital, 200 Elizabeth St-8N-842, Toronto, Ontario, Canada, M5G 2C4

Division of Nephrology, University Health Network, Toronto, Ontario, Canada

published online 14 September 2009.

Article Outline

 

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Introduction 

Given the recent results of the Hemodialysis (HEMO) and Adequacy of Peritoneal Dialysis in Mexico (ADEMEX) studies, historical concepts of dialysis adequacy were challenged after increasing small-solute clearance failed to impact on the survival of patients with end-stage renal disease (ESRD). As a result, increasing interest has shifted to augmentation of both the frequency and duration of hemodialysis (HD). Intensification of HD is achieved by increasing the frequency of therapy (in the case of short daily HD [SDHD]), duration of treatment, or both (in the case of home nocturnal HD [NHD]). Intensive HD may be performed either in-center or in the patient's home. Cardiovascular benefits of intensive HD have included improvements in blood pressure (BP) control, endothelial function, and left ventricular geometry. Other clinical benefits of intensive HD include enhanced clearance of middle-molecular uremic toxins, superior anemia and phosphate control, and improvements in sleep disorders, fertility, and quality of life. Although observational data suggest that intensification of dialysis has translated into improved clinical outcomes, confirmation through randomized controlled trials is necessary and ongoing. Few absolute contraindications to SDHD or NHD exist. These are based largely on patient motivation and support, suitability of vascular access, and, if applicable, appropriateness of the home environment. When possible, dialysis in the home should be encouraged; however, significant system and social barriers may limit the widespread use of home HD. Early patient referral, appropriate patient selection, education, and home preparation are integral components of a successful home dialysis program.

Terminology 


I.No universal nomenclature exists to describe alternative dialysis schedules1

II.Conventional HD (CHD) is intermittent HD performed in-center for 4-hour sessions thrice weekly

III.Intensive HD describes collectively all methods that offer either longer duration or higher frequency of HD compared with CHD, including (Fig 1):
A.Quotidian HD (daily HD [5-7 sessions/wk]), which may be:
1.NHD, or long nightly dialysis (during sleep)

2.SDHD, or daily dialysis of shortened duration


B.Long intermittent HD (intermittent HD [3 sessions/wk]) of increased duration:
1.Nocturnal intermittent HD (NIHD)

2.Hemeral (daytime) long intermittent HD


  • View full-size image.
  • Figure 1. 

    Methods of dialysis intensification. Abbreviations: NHD, nocturnal hemodialysis; SDHD, short daily hemodialysis. Adapted from Pereira, Sayegh, and Blake2 with permission of Elsevier.


IV.Many of these techniques can be performed at home (particularly NHD)

History of Intensive HD and Home HD 


I.1960s: Very long and infrequent HD sessions (12-18 hours) every 10-15 days out of necessity3

II.1960s: Shaldon first to offer long intermittent HD at night at home to patients dialyzing 2-3 nights/wk4, 5

III.1960s: DePalma et al6, 7 published the first study of the use of daily HD in 7 patients dialyzed 5 times/wk for 4-5 h/session

IV.1970s: use of more efficient plate and later hollow-fiber dialyzers allow for shortening the length of dialysis sessions to 3.5-5 hours

V.1970s: Tassin Center in France started and continues long intermittent HD for > 800 patients during 40 years (8 hours, thrice weekly) and reports excellent BP control and 10-year survival8, 9

VI.1980s: several groups, including Buoncristiani and Ting, establish SDHD programs in which SDHD is used as rescue therapy for patients for whom CHD failed10, 11, 12

VII.1990s: Uldall created the first home NHD program in Toronto, Canada, funded by the Ministry of Health of Ontario. The first patient was treated in 1994.13 A permanent indwelling internal jugular catheter is designed for use during dialysis at night14

VIII.2000: large NHD programs established worldwide with variable government funding. Lockridge15 leads the largest home NHD program in the United States

IX.2007: first randomized controlled trial of NHD versus CHD published16

Quantification of Solute Removal 


I.Weekly small-solute clearance is lower on peritoneal dialysis (PD) therapy compared with HD (weekly Kt/V, 2.0 vs 3.2)

II.Equivalent patient survival between PD and HD despite lower weekly small-solute clearance on PD therapy is suggestive that daily or continuous renal replacement therapy may provide improved outcomes at similar degrees of small-solute clearance17

III.No universal method exists to quantify dialysis dose across different HD schedules and various dialysis modalities (Table 1). Current measures include:
A.Standard Kt/V (stdKt/V):
1.Introduced by Gotch18

2.Calculated based on the midweek predialysis urea level

3.Assumption: mean predialysis urea level portends equivalent uremic toxicity to steady-state urea concentrations of continuous therapies (ie, continuous ambulatory PD)

4.Dialysis regimens with the same midweek predialysis blood urea nitrogen (BUN; also known as steady-state BUN) level have the same weekly stdKt/V (including native kidney function)

5.stdK = urea generation divided by mean peak predialysis urea concentration

6.Urea generation and V are calculated based on traditional urea kinetic modeling

7.stdK then multiplied by dialysis time and divided by V

8.Formula for mean peak predialysis urea concentration takes into account duration and number of treatments per week and degree of urea rebound (for intermittent therapies)


B.Normalized Kt/V:
1.Proposed by Depner19

2.Based on a hypothetical solute that has slower diffusion across the dialysis membrane than urea

3.Favors intensive dialysis because solute removal increases with time and duration


C.Equivalent renal urea clearance:
1.Proposed by Casino and Lopez20

2.Equal to amount of urea clearance provided by native kidney function (ie, amount required to produce a BUN concentration equal to the time-averaged concentration of urea [achieved on dialysis])


Table 1. Comparison of Treatment Parameters Across Intensive HD Schedules
CHDSDHDNHDNxStage HD
Treatments/wk365-66
Treatment time (h)42-36-82.5-3.5
Blood flow rate (mL/min)400400200400
Dialysate flow rate (mL/min)500800300130
Single-pool Kt/V/treatment1.20.51.80.5a

Abbreviations: CHD, conventional hemodialysis; HD, hemodialysis; NHD, nocturnal hemodialysis; SDHD, short daily hemodialysis.

aUsing Nxstage short daily prescription.


IV.Comparison of stdKt/V across dialysis modalities and schedules18 (Fig 2):
A.In PD, stdKt/V of 2.0 corresponds to a weekly Kt/V of 2.0 for PD18

B.In CHD, stdKt/V of 2.0 corresponds to a single-pool Kt/V (spKt/V) of 1.2 per treatment (minimally adequate dialysis as advocated by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative [KDOQI] guidelines)21, 22

C.In NHD, daily dialysis is associated with a lower predialysis BUN level; therefore, stdKt/V of 4-5/wk (based on daily dialysis) is achieved with a spKt/V of ∼1.8-2.5/treatment23; this is achieved even when using lower blood and dialysate flows compared with CHD18

D.In SDHD, targeting an stdKt/V of 2.0, the corresponding spKt/V typically is 0.53-0.56/treatment and equilibrated Kt/V (eKt/V) of 0.38/treatment; this is approximately half that achieved in a single CHD treatment

  • View full-size image.
  • Figure 2. 

    Relationship between weekly standardized Kt/V (stdKt/V) and equilibrated Kt/V (eKt/V) across dialysis modalities and schedules. With increasing frequency of therapy, lower eKt/V is required per dialysis session to achieve a similar stdKt/V. Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; CHD, conventional hemodialysis; NHD, nocturnal hemodialysis; SDHD, short daily hemodialysis. Adapted from Gotch18 with permission of Oxford University Press.


V.Daily HD allows for increased clearance of middle molecules because of less rebound
A.NHD increases middle-molecule removal as a result of higher frequency and duration of HD.24, 25, 26 Greater convective removal also is seen as a result of higher weekly ultrafiltration

B.In 1 study, weekly dialysate β2-microglobulin mass removal increased from 127 to 585 mg after conversion from CHD to NHD, whereas serum β2-microglobulin levels decreased from 27.2 to 13.7 mg/dL after 9 months.27 In another study, after conversion from 4 to 8 hours of HD, the relative increase in total solute removal was greatest for middle molecules, such as phosphorus and β2-microglobulin, compared with small solutes, such as urea and creatinine (Fig 3)28
  • View full-size image.
  • Figure 3. 

    Relative increase in total solute removal (TSR) associated with a change from 4 to 8 hours of hemodialysis (HD): middle molecules versus small solutes. The impact of changes in TSR on conversion from 4 to 8 hours of HD is greater for middle molecules, such as phosphorus and β2-microglobulin (β2-M), compared with small solutes, such as urea and creatinine. Source: Eloot et al.28



VI.Removal of protein-bound molecules, such as indole-3-acetic acid indoxyl sulfate, has been greater on SDHD compared with CHD29

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Home HD 

Epidemiology of Home HD 


I.Prevalence of home HD in the United States has decreased in the last 30 years
A.In 1970s, use in 40% of the US dialysis patient population30

B.In 2005, according to the US Renal Data System (USRDS), home HD constitutes 0.4% and 0.62% of all incident and prevalent dialysis patients, respectively31


II.Home HD almost exclusively available in high-income countries. Canada, Australia, New Zealand, and several European countries are among the countries with the highest prevalence of home HD32

III.Global home HD use correlated with higher prevalence of other forms of home dialysis (ie, PD)32

Patient Evaluation for Home HD 


I.Considerations for intensive HD:
A.To improve kidney disease–associated quality of life (ie, work during the day, liberalize diet)

B.To lessen intra-/interdialytic complications associated with CHD:
1.Unstable hemodynamics during CHD

2.Uncontrolled hypertension33, 34

3.Impaired left ventricular function and/or congestive heart failure35

4.Uncontrolled ascites36

5.Persistent hyperphosphatemia, metastatic calcification37, 38, 39


C.Severe sleep apnea40

D.Maintenance of home dialysis: NHD has been used successfully in patients in whom PD failed41

E.When kidney transplant is not possible or is contraindicated

F.Inadequate control of uremia (ie, large patient, poor access flow)


II.Absolute contraindications:
A.Unsuitable access for HD or access unsuitable for self-cannulation

B.Patient and/or partner unable to make appropriate decisions or follow instructions:
1.Uncontrolled psychiatric disease

2.Current drug abuse

3.Adherence issues

4.Severe dementia or encephalopathy



III.A relative contraindication is if anticoagulation is not possible:
A.For heparin-induced thrombocytopenia, may be able to use alternative anticoagulation (ie, argatroban, danaparoid, citrate-based dialysate); however, cost may limit long-term use42

B.May be able to perform saline flushes, particularly if using SDHD at home


Barriers to Use of Home HD 


I.System related:
A.Lack of experience with home HD in nephrologists and nephrology training programs

B.Small number of programs are able to offer home HD

C.Unfavorable financial reimbursement structure

D.Late referral of patients with chronic kidney disease and limited predialysis modality education


II.Patient related:
A.Patient/partner willingness to learn

B.Patient-perceived barriers43, 44: in a cross-sectional survey of 66 prevalent NHD and 153 CHD patients using validated instruments, study-specific questions, and ethnographic interviews,43 despite similar levels of education and perceived support, patient-perceived barriers in CHD patients converting to NHD were:
1)Primarily fears of self-cannulation, inability to perform dialysis at home, and a catastrophic event

2)Concerns about burden on family


C.Lack of social support

D.Medical contraindications (see previous section)

E.Poor manual dexterity

F.Poor visual acuity


III.Treatment related: lack of functional vascular access and/or fears of self cannulation43

IV.Home related: lack of appropriate home environment for HD (ie, space, telephone, lighting, plumbing, waste management).45, 46 May be overcome in part with use of novel home dialytic technologies

Vascular Access 


I.An arteriovenous fistula (AVF) is the preferred vascular access for intensive and home HD

II.Arteriovenous grafts (AVGs) and tunneled central venous catheters (CVCs) are used successfully for home HD47

III.Single-needle cannulation of AVFs and AVGs:
A.Reduces dose of dialysis by decreasing effective dialysis time and potentially increasing the degree of access recirculation (may compromise dose of SDHD)

B.May increase safety in case of accidental needle dislodgement

C.Theoretically may increase access survival because of fewer cannulation events than with 2-needle cannulation


IV.Floor moisture sensors may aid in the detection of blood or dialysate leaks and should be used48, 49

V.AVFs:
A.“Buttonhole technique” of AVF cannulation50
1.A subcutaneous tract (composed of scar tissue between the skin and the access) is created, allowing for repeated cannulation at the same arterial and venous sites

2.One of several methods of AVF cannulation in large home HD centers and self-care HD patients51

3.Reports of greater patient comfort and greater ease of self-cannulation than the traditional “rope ladder” technique51

4.Allows use of noncutting needles, which are guided into the fistula through a tract and may be associated with a lower incidence of blood leak

5.Meticulous attention to scab removal and aseptic technique necessary to limit risk of local and systemic infection


B.Taping of a moisture sensor (such as an enuresis alarm or newly developed sensor patch) close to the fistula needle sites may allow the patient to recognize early needle dislodgement48, 49, 52

C.Observational studies suggest no increase in risk of AVF complications for NHD and SDHD compared with CHD53, 54


VI.CVCs:
A.Use of preperforated nonremovable CVC caps (ie, Interlink [Becton Dickinson, NJ, USA], Tego [ICU Medical Inc, San Clemente, CA]) may minimize the risk of air embolism by obviating the need for cap removal for HD

B.Nondisposable locking box may prevent accidental separation of blood tubing and catheter

C.Prospective observational study suggests that the incidence of catheter-related bacteremia is similar between CHD and NHD patients55

D.Review of sterile technique should be encouraged after an episode of catheter-related bacteremia. Self administration of antibiotics during treatment is possible

E.Potential for longer catheter survival with NHD, which may be caused by greater cumulative exposure to anticoagulation55

F.Initiation of NHD with a CVC may be followed successfully by creation of an AVF, but will require retraining for self-cannulation


VII.AVGs:
A.Buttonhole technique is not possible with AVGs, and self-cannulation of access may be more challenging than with AVFs

B.No increased risk of AVG complications or reduced survival when used for SDHD compared with CHD53, 54

C.Single-needle cannulation may be particularly useful with AVGs to allow self-cannulation


Remote Monitoring and Home HD 


I.Remote monitoring may be achieved using telephone or Internet connection

II.Practiced by several dialysis centers; in absence of a partner, some centers/jurisdictions mandate remote monitoring56, 57

III.Centralized monitoring of large numbers of patients improves cost-effectiveness

IV.Observer may respond to alarms unattended by the patient, help with patient troubleshooting after hours, or mobilize emergency services as needed

V.May aid in documenting adherence to treatment regimens

VI.May provide patient reassurance, particularly during the first several months of home HD

VII.May allow for data collection to study physiological effects of NHD

VIII.Incremental safety of remote monitoring requires further prospective study

Advances in Home Hemodialytic Technologies 


I.Standard HD machine may be used for all forms of intensive HD

II.Attempts to modify standard HD machines for use at home may aid in the adoption of home HD58, 59, 60, 61

III.Emerging design of HD machines specifically for use at home is engineered to obviate the needs for home electrical and/or plumbing modifications
A.Aksys Personal Hemodialysis System62:
1.Online ultrapure dialysate (which may be used for intravenous infusion, obviating the need for saline bags)

2.Hot water disinfection allows dialyzer reuse and tubing (reduces storage requirements and waste)

3.No longer available


B.NxStage System One (NxStage, Lawrence, MA)63:
1.Smaller than traditional HD machines (70 lb)

2.Uses 4-6-L preformed bags of ultrapure dialysate
a)Obviates need for electrical connections, plumbing, or modifications

b)Can perform dialysis away from home


3.Licensed for daily HD at home

4.Online dialysate production possible for patients who need increased clearance (Nxstage PureFlow SL)

5.Dialysate flow rates determined to achieve a target flow-fraction of 35% (range, 25%-40%), in which flow fraction is defined by dialysate flow rate + ultrafiltration rate divided by blood flow rate


C.Renal Solutions Allient Sorbent Hemodialysis System (Allient, Warendale, PA)64
1.Sorbent cartridge-based system designed for 3-8-hour sessions

2.Requires electrical source and 6 L of drinking water

3.Water is mixed with small packets of dry chemical and converted to dialysate by the sorbent cartridge

4.Continuous dialysate regeneration by sorbent cartridge

5.Possibility for smaller travel-friendly sorbent device in the future

6.Not widely available at present



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Clinical Benefits of Intensive HD 

A summary of the clinical benefits of intensive HD is listed in Table 2.

Table 2. Clinical Benefits of Intensive Hemodialysis
Nocturnal HemodialysisShort Daily Hemodialysis
Blood pressure control
+++

(↓ total peripheral resistance)


++

(↓ extracellular fluid volume)

Left ventricular hypertrophy
+++

(↓ afterload)


++

(↓ preload)

Left ventricular systolic function+++Not shown
Arterial compliance+++Not shown
Sleep apneaCorrectionNot shown
Cardiac autonomic nervous system abnormalitiesRestorationNot shown
Phosphate control+++Depends on duration
Anemia
++

(↓ erythropoietin resistance)


+

(↓ erythropoietin resistance)

Malnutrition++++
Inflammation↓ C-reactive protein, interleukin 6↓ C-reactive protein
Cognition+Not shown
Fertility++Not shown
Quality of life++a++

aImprovement in kidney-specific domains of quality of life.

Cardiovascular 


I.BP
A.Superior control of BP with fewer or no medications with both SDHD and NHD shown by multiple observational studies and 1 randomized controlled trial16, 48, 49, 65, 66, 67

B.Restoration of normal BP in 28 patients followed up for 3 years after conversion to NHD from CHD. Mechanisms of improvements in BP between SDHD and NHD may differ66:
1.SDHD: decrease in extracellular fluid volume68

2.NHD: decrease in peripheral vascular resistance and lower levels of circulating catecholamines69



II.Left ventricular geometry
A.Reduction in left ventricular mass index using 2-dimensional echocardiography in several prospective observational studies of patients converted from CHD to SDHD or NHD16, 65, 66, 70

B.In a recent randomized controlled trial, 52 CHD patients at 2 Canadian centers were randomly assigned to CHD versus 6-times-weekly NHD.16 The primary outcome, left ventricular mass index (assessed using cardiac magnetic resonance imaging), was significantly decreased in the NHD group (mean difference, 15.3 g; 95% confidence interval, 1.0-29.6)

C.Improvement in left ventricular systolic function in patients converted to NHD from CHD in those with pre-existing impaired left ventricular ejection fraction35

D.Restoration of endothelial progenitor cell number and function in patients converted from CHD to NHD.71 Improved endothelial progenitor cell number and function were directly related to intensity of dialysis and inversely proportional to left ventricular mass index


III.Endothelial function: improvements in endothelial-dependent (postischemic vasodilatation) and -independent vasodilatation (response to nitroglycerin) were noted after conversion from CHD to NHD69

IV.Coronary calcification: in 1 prospective observational study, 38 patients had coronary artery calcification scores (using multislice computed tomography) measured before and after conversion to NHD.72 No change in coronary artery calcification scores was noted in patients with low baseline scores (<10). In patients with scores > 10, a nonsignificant increase was seen at 1 year

V.Autonomic nervous system
A.Partial restoration of heart rate variability during sleep with NHD73

B.Improvement in baroreceptor sensitivity and decreased circulating levels of catecholamines with NHD69

C.Decrease in sympathetic activity upon conversion to SDHD74


Anemia and Erythropoietin Responsiveness 


I.Conflicting reports of the impact of intensification of HD on the management of anemia
A.SDHD:
1.Woods et al75: increase in hematocrit by 3% on conversion to SDHD in 72 patients

2.Ting et al12: conversion to SDHD from CHD associated with a decrease in recombinant human erythropoietin (rHuEPO) requirements by 45% and increase in hemoglobin (Hb) concentration


B.NHD:
1.Compared with 32 self-care CHD control patients, conversion to NHD in 63 patients was associated with an increase in Hb concentration and concomitant decrease in rHuEPO requirements76

2.Conversion to NHD from CHD is associated with improvement in hematopoietic progenitor cell growth (in vitro) and upregulation of genes relevant to hematopoietic progenitor cell growth mobilization and red blood cell production77

3.rHuEPO dose or change in Hb level was not different in the control and treatment groups in a randomized controlled trial by Culleton et al16 (may be underpowered because this was not the primary outcome)



Phosphate Control and Mineral Metabolism 


I.SDHD:
A.Increased phosphate removal by SDHD compared with CHD78

B.Improvement in serum phosphate level shown if duration of SDHD > 2 h per session12, 78, 79


II.NHD:
A.Phosphate removal during NHD ∼2 times greater than CHD

B.Patients no longer require phosphate binders on NHD therapy16, 38

C.Removal of dietary phosphate restrictions38

D.Normalization of calcium-phosphate product39

E.Intradialytic phosphate supplementation may be required in some NHD patients to avoid hypophosphatemia.38, 49 Requirements may increase in:
1.Pregnancy80

2.Bone repair states


F.Phosphate supplementation:
1.Achieved by the addition of sodium phosphate (in the form of Fleet enema or Fleet Phosphosoda [Fleet, Lynchburg, VA]) to the acid concentrate

2.Typical dose is 60-90 mL/treatment

3.120 mL of Fleet added to acid dialysate concentrate yields a final dialysate phosphate concentration of ∼1.0 mmol/L

4.Calcium and phosphate do not precipitate in the presence of the acidic pH of the “acid concentrate”81

5.Titrate dose to maintain pre- and postdialysis phosphate levels within normal range


G.Risk of negative calcium balance due to minimal use of calcium-based phosphate binders. Risk increases with higher rates of ultrafiltration, in which calcium loss may be greater82

H.NHD may be a therapeutic option for patients with tumoral calcinosis or calcific uremic arteriolopathy, particularly if calcium-phosphate product is high at time of diagnosis37

I.Dialysate calcium must be titrated high enough to increase serum calcium levels during dialysis82
1.Postdialysis hypercalcemia is required to titrate appropriate dialysate calcium

2.Mean dialysate calcium concentration, −6.41 mg/dL (−1.6 mmol/L)

3.Bone densitometry may be a useful tool to guide dialysate calcium supplementation39

4.Normalization of alkaline phosphatase and maintenance of parathyroid hormone levels within recommended range

5.Calcium addition to the dialysate can be achieved by adding calcium chloride powder to dialysate (addition of 7 mL to 4 L of acid dialysate concentrate increases dialysate calcium by 1 mg/dL [0.25 mmol/L])82


J.Use of vitamin D analogues may be beneficial to maintain calcium balance and normalize serum phosphate level


III.Conversion to NHD from CHD is associated with increases in 1,25-dihydroxyvitamin D and 25-hydroxyvitamin D levels independent of exogenous supplementation83

Malnutrition and Inflammation 


I.Patients converted to daily HD therapy experience improved appetite, weight gain, and muscle mass increase,84, 85 which may be caused by liberalization of the diet (ie, sodium, potassium, phosphate) and superior control of uremia84, 86, 87

II.Despite daily amino acid losses of 10 g into dialysate, total-body nitrogen measured using in vivo neutron-activation analysis did not show a decrease in 24 patients followed up on NHD for 15.7 months88

III.Several studies have reported increases in serum albumin levels after conversion to SDHD and NHD, whereas others have not.12, 48, 79, 85 This may be the result of varying patient selection criteria and length of follow-up

IV.Chazot et al89 have shown stability of nutritional parameters at 5 years' follow-up in patients treated with long intermittent HD

V.Reports of decreased levels of inflammatory markers on conversion to daily HD (ie, C reactive protein [CRP] and interleukin 6 [IL-6])90

VI.Because of increased loss of water-soluble vitamins, the dose of daily multivitamin preparation is increased to 2 tablets/d.48 No conclusive evidence of vitamin deficiency has been reported

Sleep Disorders 


I.Sleep disorders, including sleep apnea syndrome (SAS), restless legs syndrome, and periodic limb movement disorder, are seen with increased frequency in patients with ESRD91

II.The prevalence of SAS is as high as 50%-70% in patients with ESRD91

III.SAS is associated with daytime sleepiness, heightened cardiovascular morbidity, and mortality92

IV.Conversion to NHD from CHD is associated with improvements in SAS40, 73

V.No improvement in daytime sleepiness or periodic limb movement disorder of sleep after conversion to NHD from CHD93

VI.No published data regarding the effects of SDHD on sleep disorders

Fertility 


I.It is recommended that dialysis be intensified for pregnant patients on CHD therapy or patients with stage 5 chronic kidney disease intending to become pregnant

II.Decreased fertility and increased maternal-fetal morbidity and mortality for patients on CHD therapy94

III.NHD may allow for improved fertility80

IV.Delivering a live infant at a mature gestational age is feasible for patients on NHD therapy80, 95

V.In a single-center cohort study of 7 pregnancies in 5 patients while on NHD therapy, fewer maternal and fetal complications were noted compared with historical CHD controls80

VI.In a large registry study performed in the United States, there was a nonsignificant trend toward improved maternal survival and decreased preterm delivery in patients who received > 20 h/wk of dialysis96

Cognition 

Conversion to NHD from CHD is associated with improved psychomotor efficiency and increased attention and working memory.97

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Quality of Life 


I.Quality of life and vocational abilities are traditionally poor in patients with ESRD98

II.Use of a variety of self assessment questionnaires (such as the 36-Item Short Form Health Survey [SF-36], Sickness Impact Profile, and Beck Depression Inventory) has shown improvements in most parameters after a switch to NHD from CHD in prospective observational studies84, 99

III.In a randomized controlled trial, NHD was associated with significant improvements in selected kidney-specific domains of quality of life (effects of kidney disease and burden of kidney disease) compared with CHD.16, 100 No difference in overall quality of life (assessed using the EuroQol-5D index) was seen between the 2 groups

IV.In a cross-sectional study of comparison of quality of life and illness intrusiveness in patients treated with home dialysis (either NHD or PD), NHD was not perceived as a more intrusive treatment compared with PD.101 Similar perceived symptomatic control of kidney disease was seen between the 2 groups

V.Using utility scores (which measure overall quality of life by assessing a patient's preference between health states), McFarlane et al102 and Heidenheim et al103 showed higher utility scores with NHD compared with CHD

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Cost-Effectiveness 


I.Because of the increased frequency of NHD and SDHD, the cost of consumables is higher compared with CHD

II.Personnel cost of NHD is lower than that of CHD and SDHD in North America104

III.In developed countries, cost of personnel is greater than the cost of consumables. Depending on the ratio of cost of personnel to cost of consumables, NHD may be less or more expensive than in-center HD

IV.Lower rate of medication use (rHuEPO, antihypertensives, phosphate binders) may decrease total costs of NHD16

V.Decreased hospitalization rates reported with NHD compared with CHD12, 105

VI.In 2 prospective randomized studies comparing the costs of CHD versus NHD in Canada, treatment costs for NHD patients were 20% lower than those for CHD106, 107; similar findings in 1 US study99

VII.Improved cost and quality of life have translated into higher cost-utility scores for NHD compared with CHD102

VIII.Limited studies regarding the cost-effectiveness of SDHD alone compared with CHD and NHD; 1 retrospective study using cost data obtained from the USRDS, Centers for Disease Control and Prevention (CDC), and Medicare Payment Advisory Commission showed that a decrease of at least 8% in hospital days are required for daily dialysis to be cost saving99

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Future Directions 


I.Despite several reported clinical benefits, the impact of intensive HD on survival is unclear

II.Observational studies suggest that both SDHD and NHD are associated with improved survival compared with CHD.75, 108, 109, 110 These studies need to be interpreted in the context of the study design, in which patient selection for intensive HD may be limiting adequate adjustment of residual confounding
A.SDHD: in 1 series, 5-year survival of 80% reported.75 In a second series, 5-year survival of 68%, which was 2-3 times better than the survival of matched (age, sex, primary diagnosis) 3-times-weekly HD patients, was reported by the USRDS111

B.NHD: 5-year survival of 81%108


III.According to USRDS data, use of any form of home HD was associated with a 44% decreased risk of death after adjustment for age and comorbidities compared with in-center HD112

IV.Equivalent survival shown between 177 Canadian NHD patients and 513 deceased donor kidney transplant recipients matched on the basis of race and cause of ESRD and after adjustment for age, sex, and comorbid conditions113

V.The development of an intensive HD registry and prospective randomized studies sponsored by the National Institutes of Health (NIH) and Centers for Medicare & Medicaid Services (CMS) will shed further light on the impact of intensive HD on important clinical end points114, 115, 116, 117

VI.The Frequent Hemodialyis Network (FHN), sponsored by the NIH and the CMS, currently is sponsoring 2 randomized clinical trials:
A.The first will randomly assign patients to an in-center daily (6 times weekly) versus a conventional in-center (3 times weekly) HD regimen. Anticipated differences in weekly median treatment time and stdKt/Vurea between the control and treatment groups are 29% and 52%, respectively118

B.The second trial will compare a regimen consisting of 6 weekly 8-hour nocturnal treatments versus three 4-hour conventional treatments. Anticipated differences in weekly median treatment time and stdKt/Vurea between the control and treatment groups in the second trial are 234% and 133%, respectively.118 This is a substantially greater difference than that achieved in the HEMO Study, in which only a 17%-18% difference in median treatment time and stdKt/Vurea was achieved between the treatment and control groups.119 This may explain in part the inability of the HEMO Study to show a survival benefit to an increase in delivered dialysis dose


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Acknowledgements 

This article is dedicated to the memory of Dr Robert Uldall.

Support: Dr Perl holds a Kidney Foundation of Canada Biomedical Fellowship. Dr Chan holds the R. Fraser Elliott Chair in Home Dialysis.

Financial Disclosure: None.

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 Originally published online as doi: 10.1053/j.ajkd.2009.06.038 on September 14, 2009.

PII: S0272-6386(09)00984-6

doi:10.1053/j.ajkd.2009.06.038

American Journal of Kidney Diseases
Volume 54, Issue 6 , Pages 1171-1184, December 2009

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