HOME HEMODIALYSIS (HH)

HH started in the early 1960s in Boston & London. Current studies since that time have shown better survival & quality of life for ptns on conventiona

 

Home hemodialysis (HH)

 

 

Literature review current through: Jan 2022. | This topic last updated: Feb 26, 2020.

 Abbreviations:

o   BP: blood pressure

o   CKD: chronic kidney disease

o   Dc Np: diabetic nephropathy

o   DOQI: Dialysis Outcomes Quality Initiative

o   DX: Dialysis

o   Dzr: dialyzer

o   Dzt: dialysate

o   EPO: erythropoietin

o   ESA: erythropoietin-stimulating agents

o   ESRD: end-stage renal disease

o   FDA: US Food and Drug Administration

o   Hct: hematocrit

o   HDX: Hemodialysis

o   HH: Home HDX

o   HT: hypertension

o   KDOQI: Kidney Disease Outcomes Quality Initiative

o   KTx: Kidney transplantation

o   LVH: left ventricular hypertrophy

o   MR: Mortality rate

o   OPD: Outpatients department

o   PD: Peritoneal dialysis

o   RF: renal failure

o   RR: risk ratio

o   RRT: renal replacement therapy

o   Sms: symptoms

o   ttt: treatment

o   UF: ultrafiltration

o   USRDS: United States Renal Data System.

 

 

HH started in the early 1960s in Boston & London. Current studies since that time have shown better survival & quality of life for ptns on conventional, thrice weekly HH in comparison with ptns on other DX modalities. In regard to the cost, it has significant less costing than conventional in-center HDX that led some authors to believe that HH is better as compared to KTx. Despite the given benefits, the % of prevalent DX ptns with ESRD on HH in the US has increasingly dropped from the start of the Medicare ESRD program in 1973 until 2002, to became 0.57 %. Similar alterations have seen in other countries. Since 2002, there has been a gradual rise in the quantity and % of all US DX ptns on HH; by 2008, 3826 ptns (1.09 %) on HH, have been reported and along 2010 suggested that the quantity of ptns was 5000-6000 that reflecting a rising interest in HH. Considering the USRDS 2013 data for incident 2011 ptns, total HH ptns have been rising but mainly related to the significant rising in ptns on continuous cycler PD. Actually, there’re several barriers to ptns choosing the home modality.

 INCIDENCE/PREVALENCE

The quantity of ptns ttt with any home DX modality (HDX or PD) has declined along 10 ys from 1996-2008, when the trending starts to change. By 2010, a large rise in all HH has been observed, with mostly new ptns on PD. Moreover, there was also clear rise in HH by 2011-2013, though < 1500 ptns out of about 13,000 ptns have chosen the home modality. The entire therapy of HH still diminished. Among incident ESRD ptns, only 9.1 % of home DX ptns were maintained on HH in 2013.

Worldwide, there’s little or no HH, except in few numbers of high-incomed countries with an annual per capita national income > US $10,000, and, until recently, the number of home DX ptns had been mostly dropped in these areas. In 2006, there was chance for significant extension in HH therapy in many countries. Such extension has been observed in the US and elsewhere. A DX economic has been developed by an international group of nephrologists observed that the increasing home-related modalities (including PD) may help addressing the growing DX burden all over the world. New HH programs have been addressed in Turkey, India, China, and Hong Kong.

 

REASONS FOR THE DROP IN HH

The current lack of HH modality for ESRD therapy in the US may be attributed to:

1)    Higher numbers of old ptns or seriously ill, particularly those whose ESRD related to DM or intense vascular disease.

2)    The rapidly rising number of out-ptns in DX units, especially for-profit units that did not encouraging HH, although this may be changing.

3)    The concept that ptns should not be dialyzed without direct nurse supervision.

4)    Poor knowledge about the advantages/disadvantages of various DX modalities

5)    Absent ptn/family motivation, ptn fears to be sticked themselves, socially isolated, HDX techniques, and fear of managing blood access and machines and the expected higher burden on the family. All these can be overcome by a sympathetic staff convincing ptns that HH is a superior type for ESRD.

6)    Absent attention to HH, self-care HDX, and PD by many training programs.

7)    Lacked interest & experience with HH among most nephrologists.

8)    Little number of proper DX programs for ptns’ training in HH.

 

IMPROVED OUTCOME

However, HH of increasing attention as a valuable modality for several reasons:

1)    Realizing HH provides better outcome, better survival, better control of HT with few/no anti-HT drugs, better life quality and opportunity for re-employment, with more cost effectiveness and no adverse impacts on fistula survival.

2)    A longer and/or more frequently provided HDX is best given at home.

3)    A long-term and better DX adequacy with PD.

4)    Future concerns: Whilst growth in ESRD incidence in the US has been slowed along the last years, new cases grew by 3.4 % between 2005 & 2006, the 1^st growing of > 3 % since 2001. However, since that time, growing rate has flattened repeatedly, to be only 0.06 % between 2006 & 2007 and 1.2 % between 2007 & 2008. Growing of prevalence rate has been flattened along the same time period, from 3.2 % to -0.9 % & 0.08 %.

5)    Cost concerns: In 2008, Medicare spent USD $26.8 billion on ESRD that equals about 5.9 % of its entire budget. Non-Medicare ESRD = USD $12.7 billion, with a total costing of mostly USD $39.5 billion.

6)    Shortage of nephrologists will continue and will be compounding by the required care for a rising number CKD ptns. Also does the shortage of nurses.

 

The studies assessing ptns’ survival on conventional HH reported general survival rates of almost 90 & 50 % at 5 & 15 y.s, resp.. Although these reports were proceeded by authors who’re favoring using this modality, the following data from a report using the USRDS database are corroborating these findings:

o   Ptns on HH had an unadjusted lowered mortality risk compared to ptns dialyzed as OPD (RR: 0.37 s 1.00).

o   Adjusting age, diagnosis, comorbid diseases, and gender did not significantly alter the lowered risk of mortality in HH ptns, despite this cohort was younger with less comorbid disease than general DX cohort (RR: risk ratio 0.56 vs 1.00).

This improved survival, however has also been found outside the US e.g.,

o   French registry: improved 5- & 10-y. survival compared with DX in a center (79 vs 59 % and 56 vs 32 %, resp).

o   Nested case-control report: (Switzerland), 58 HH ptns matched with an in-center HDX ptns for sex, age, DX vintage, and kidney disease via retrosp. analysis. 5-, 10-, & 20-y survival was greatly higher with HH (93, 72, and 34 %, resp., vs 64, 48, and 23 %).

o   Database analysis (Australia & New Zealand): MR risk was 50 % lower among HH ptns compared to in-center HDX between 1996 & 2011, noting that HH ptns were younger with fewer comorbidities as compared to in-center ptns.

Ptns maintained on a such DX modality at home as those who’re dialyzed in-center, the reasons of improved survival are not well certain (except for selection bias). Blagg & Scribner alarmed the need for DX ptns to keep their independency avoiding the syndrome of "learned helplessness". Ptns exerting enough responsibility and mostly know about their disease feel "in charge" of their own ttt achieving more favorable outcome. Similar psychological factors may play a robust role in HH ptns. Such ptns may also be less likely to dedicate portions or timing from their therapy, esp. those on overnight DX.

AUGMENTED DX

Prolonged conventional DX, thrice weekly, is associated with improved survivals e.g., among the best ptn survival findings in the world are those from Tassin, France showing the remarkable benefits of thrice weekly, 8-h DX in center or at home. After 5 ys, ptns showed no evidence of progressive nutritional deficits observed in HDX (HEMO) trial. In Australia, many DX centers have adopted HH that’s synonymous with extended-h.s DX due to survival, physiologic, quality-of-life, social, and economical benefits.

More benefits can be expected with more frequent short daily and/or long nightly HDX, both of them can be mostly easier at home. Benefits may include more adequate DX with a higher Kt/V, better BP management with fewer or no agents, regressed LVH and reduced inflammatory markers, significant improvement in removing PO⁴ and B₂ microglobulin (esp. with nocturnal HDX), subjective improving in ptn wellbeing both during and between sessions, better nutrition and quality of life.

However, considering the increased supplies, more frequent HDX usually costs more, even if at home. So, it should be realized that overnight nocturnal HDX 3 times a week can provide the double as many h.s of DX/week compared with conventional in-center HDX as the practice in the US, less costing, and better outcome.

Long, alternative-night HDX at home/center is a marvelous compromise. It removes the weekly 2-day gaping between sessions at weekends, and it has been observed that there’s a threefold raising risk for sudden death in the 12 hs before DX after the weekend. While it’s not as efficacious as overnight HDX 6 nights a week requiring more UF, it induces relatively better PO⁴ control; however, it cannot eliminate PO⁴ binders requirement. One report: it can manage the biochemical agents related to bone mineral metabolism almost like nightly and daily short DX. Considering costing and consumable requirements are nearly less than that with nightly and daily HDX, extension of this regimen should be considered.

The 2015 KDOQI guidelines: considered home long HDX 3-6 nights/week, recommending that ptns considered for this modality should be informed about the related risks that may include:

1)    Potential rise in access complication(s),

2)    Higher burden for the caregiver(s), &

3)    Rapid loss of the residual kidney function.

MECHANISM OF BENEFITS

Prolonged, thrice-weekly DX sessions and/or more frequent HDX have variable impacts that could be contributing to the clearly improved outcome. One crucial difference is the ameliorated abnormal physiological cycling of body water, blood osmolality, and total body solutes that seen with intermittent/intense conventional DX modalities. Short/long daily DX almost invariably resulting in clearer ptn benefits compared with overnight HDX 3 times/week, and, at least with short frequent DX, this’s not necessarily related to the higher weekly DX dose. Despite the developed Kt/V urea has considered the common mathematical tool to calculate the DX dose with more frequent sessions, PO⁴ and middle-molecule removal are mostly more crucial than small-molecule elimination and augmented with increased weekly DX dosing.

Where lab profiles to estimate removal of B₂-microglobulin are not currently available, rather than relying on the Kt/V, the quality of DX may be best assessed from ptn outcome and clinical Sms, e.g., effective DX therapy may be best proved by a better quality of life that’s partially defined by lowered needs for EPO and anti-HT drugs, better appetite with absent fatigue and pruritus.

POSSIBLE TECHNIQUES TO REVERSE THE DROP IN HH

Several obstacles must be overcome to augment the % of ESRD ptns amenable for HH modality and more frequent DX dose. The suggested steps that nephrologists can admit to reverse the declining trend may include:

1)    Early recognition of potential HH ptns.

2)    Early referring to a designated HH training program.

3)    Early placing of an effective A/V fistula.

4)    Physicians/staff must devote more timing emphasizing the benefits of HH: freedom, training of techniques, independency & support, flexible schedules of DX, better personal relationship with staff, and, particularly, better ptn survival with HH with longer and/or more frequently provided DX.

5)    Education programs encouraging questions/discussions and in particular targeting all ttt options to pre-ESRD ptns.

6)    Developing central coordination of regional HH centers to provide resources with the best specialized training staffs (successful in British Columbia).

7)    New access modality and equipment to augment the prescribed DX, with more frequent DX, decreasing morbidity, and simplifying DX.

8)    Recent technology providing simple/safe DX and for ptns to perform, with little help from family members or others. One survey: ptns and family may provide remote control for nocturnal HH, at least with transition from training to HH.

9)    Recognizing: thrice weekly HH is significantly less costing than in-center HDX.

10) Programs for conventional HDX ptns participating in a short, in-center, frequent DX clinical trial (2-3 weeks) to identify the benefits of more frequent HDX.

11) Changing the reimbursement policy of Centers of Medicare/Medicaid Service paying more attention to frequent DX. There’s evidence that conventional HH thrice weekly and more frequent DX in particular, either short daily or long nightly, may induce overall saving, as reduced staff timing, less timing/frequent hospitalization, and lowered EPO/anti-HT agents needs.    

 

 

Morbidity/MR from DX is generally have declined only slightly among ptns in the US, despite the implemented DOQI guidelines and improving Hct, serum albumin, & Kt/V values. Moreover, the HDX (HEMO) study declared that thrice weekly HDX, augmenting the dose of DX above DOQI-recommended guidelines or with high-flux membranes had no significant impact on hospitalization or ptn MR. MR   still compares unfavorably with that of Japanese, Western European, and Australian HDX ptns.

 

BARRIERS TO EXTENDED USE OF HH MODALITIES

There’re multiple barriers to use HH modalities:

o   Absent educated physicians, ptns, & DX staff

o   Re-imbursement

o   Ptns feelings about staff abandonment.

It’s possible that HH declining can be reversed now that the barriers have been identified. HH can provide several benefits that there’s considered chance for more DX delivery with improved outcome. To overcome these hurdles, it’s necessary for the clinicians to take a step with staff and ptns choosing in advance those who’re likely candidates for one of the HH modalities.

HH MACHINES

To continue the improvement, recent approaches/techniques have to be introduced to provide HH delivery of more frequent modules and more physiological DX at home. A variety of machines dedicated for HH have been admitted or are under evolution:

o   Aksys PHD was the 1^st machine provided specially for easily using and had FDA clearance in 2002. It can provide ultrapure Dzt that’s ready also as replacement fluid (exempting IV saline), and using hot water for disinfection to allowing Dzr & tubing set reuse in situ for > 30 use(s) (significant decline DX supplies & medical wastes). It has relative biocompatibility and met 2001 FDA criteria for non-DEHP use for repetitive use, including HDX.

o   Disadvantages may include its large size/weight; the need for plumbing & electricity at home, with some rise in bills; and its complexity that can be managed by company's technicians. It’s no longer available as the Aksys Company has bankrupted in 2007.

o   NxStage System = small (only 70 pounds), more transportable machine than the older ones using 4-6 5-L bags of ultrapure lactate Dzt integrating onto a disposable cassette for each short daily DX, so, increased storage space needed at home. As no need for electrical/plumbing facilities, ptns can perform DX away from his home without arrangement with other DX units. It’s easier for ptns to learning to use. Larger ptns may require 5-6 bags of Dzt to get adequate DX. Considering the consumption of Dzt bags with new Dzr/tubing set for each DX session, there’s more plastic exposure with more medical wasting.

o   The NxStage PureFlow SL prepares > 60 L of Dzt (enough for 3 ttt) using a pre-packaging filtering system that allow ptn to prepare Dzt from tap water, avoiding the need for Dzt bags, except if he’s traveling.

o   The Renal Solutions Allient Sorbent HDX System was a sorbent cartridge-based system, used at home and outside. It was also ptn friendly, only needs an electrical port with 6 L. of drinking water for ttt. Water can be mixed with small packages of dry chemicals to be converted to Dzt via the sorbent cartridge, and the Dzt was permanently regenerated & recirculated. Overnight ttt was amenable as the sorbent cartridge was designed for 3-8-h. sessions. Renal Solutions was purchased by Fresenius in 2007, it’s anticipated to be adapted with the sorbent technology in Fresenius machines.

 

 

Every system is usually focusing on the introduction of several program schemes to induce easier/safer procedure, including:

1)    Better computer monitoring,

2)    Better sterilization technique, &

3)    The feedback designing.  

Other areas of interest are related to wearable artificial kidney and the implantable artificial kidneys. The 1^st is developed by some small companies, and at least one of them is undergoing clinical assessment. The biggest inquiry with the wearable device is blood access, and so 2 groups are designing wearable PD devices.

The evolution of an implantable artificial kidney based on the University of Michigan Renal Assist Device has been admitted for many years. It’s not expected to be exposed for clinical testing for several years. Finally, it’s important to highlight that PD is also a variety of home ttt that may play a wider role in the future.

 

APPROACH

Every member in the DX team must become advocated for HH and for more frequent DX if it became feasible. Until that time, conventional overnight thrice weekly or alternate-night HDX, either at home or in a center, is suggested to be an optimal ttt schedule. By the end of the year 2007, 841 ptns were on conventional HH thrice weekly, 302 on alternate nights, 2396 on short daily, and 225 were on HH 5-6 nights per week.

Despite the difficulty to receive potential ESRD ptns early in the course of RF, nephrologists must stress upon their colleagues that ptns on stage 3 & 4 CKD should be referred as early to teach them how to manage their disease and to inform them about the benefits of HH, more frequent HDX, PD, and Tx.

This information may help reducing ptn fear and depression. It will also make it possible for ESRD ptns to manage their illness more realistic and provide them the opportunity to select the best module of DX ttt. The website, Home hemodialysis Central, is a marvelous resource for ptns interested in home DX.

Trials that reported better ptn outcome with HH and more frequent HDX highlight the vitality of ptns information about various modalities of HDX feasible to them and, in particular, the benefit (s) of HH and more frequent HDX. Clinicians in the US & Canada believe that home DX therapy is underused and that 11-14 % of all HDX ptns are candidate for ttt by HH. A 2007 survey of 6595 delegates at 5 international HDX & nephrology conferences (57 % physicians & 28 % nurses) found that they’re mostly considering frequent home or self-care HDX the best long-term modality. Furthermore, at least 2 informal polls of nephrologists asked what ttt they would prefer, if Tx was not feasible, found the vast majority would prefer HH, whether they had home DX ptns or not.

So, nephrologists and the entire DX staff should not let their emotions or economic requirements deciding the DX modality if there’s any chance of the ptn choosing HH. This modality of ttt is still the best option for many cohorts of ptns than already had the opportunity for it.