History

In the 1960's during the early days of home hemodialysis, most treatments were done in the home, primarily because of the lack of hospital or clinic-based facilities. By 1973, 40% of dialysis patients were doing their treatments at home.

Decline of Home Hemodialysis

The percentage of home hemodialysis patients began to drop after 1973. Today the situation has almost reversed and most people on dialysis (90%) get their treatments at a dialysis center.

The drop in home hemodialysis was caused by the following:

• In 1972, Congress passed legislation that created a Medicare program to pay for dialysis treatment. This program made in-center hemodialysis financially more attractive to providers so dialysis centers started being built. These new centers were staffed by nurses and technicians. Centers could pay for these costs by treating more patients.
• As more people got dialysis they were able to live longer. Since they lived longer they began to develop other chronic conditions and complications.
• Throughout the 1970’s and 80’s, peritoneal dialysis (PD) began to become more popular, which led to less people choosing home hemodialysis.
• Until recently, all hemodialysis machines were built for use in the dialysis center. They were large, considered hard to use, and believed to be too expensive to be used at home.
• As the number of people getting treatment in centers grew, the number of centers that could offer home hemodialysis began to shrink.

New Interest in Home Hemodialysis

Home Hemodialysis is growing more popular among patients and doctors for the following reasons:

Doctors now recognize that home hemodialysis can give patients more benefits:

•  Treat more patients more cost-effectively
•  Reach more patients from rural regions
•  Add a valuable new service to an existing in-center program
•  Bring many of their patients improved quality of life

 Patients understand that hemodialysis might help them:

• Feel better, maintain their lifestyle and help them have control over their disease
• Keep working and be more active
• Have freedom and flexibility to travel with their therapy with newer, portable machines

New data has shown that more frequent home hemodialysis may lead to better health with fewer problems, and because of new technology the number of people choosing home therapy has grown significantly.  

To find if home hemodialysis is right for you, talk to your health care team about home hemodialysis. To find a home hemodialysis provider in your area go to www.homedialysis.org/locate [1] or www.nxstage.com/find-a-center [2]. 

Is More Frequent Hemodialysis Better?

Since the early days of dialysis, doctors quickly learned that 1-2 treatments per week did not clean the blood well enough. Many patients seemed to do well with a treatment schedule of three times per week so that was set as the established regimen. However, we have known since the 1980’s that the mortality ,rate of death, for dialysis patients is high. Recent studies have suggested that more frequent and longer treatments may offer significant benefits to health and well being.   

In order to provide treatments more often or for longer time periods, patients have to be cared for in a different way. A “one-size fits all” treatment system does not work for many people and may cause complications such as heart disease.

Worldwide, very few dialysis patients receive treatments five or more times per week even though reports show that patients receiving more frequent dialysis experience fewer deaths and improved health. Dialysis center schedules are set to do treatments three times per week so it is generally much easier to schedule more frequent treatments at home.

Benefits that may be experienced include:

• A significantly lower risk of death.
• Reduced stress on the heart caused by fluid buildup.
• Significant, lasting improvement in symptoms of depression.
• An 85% improvement in the time it takes to “recover” after each treatment, from nearly nine hours to about one hour, on average.
• Fewer problems with high blood pressure, putting less strain on the body and heart. Many patients and doctors report being able to cut down or eliminate the amount of medicines needed.
• Improvement in health-related quality of life scores, including physical and mental functioning.
• Improved appetite with fewer fluid and dietary limits.
• Increase in energy and vitality so that patients can go back to work and take care of their families.

Quality of Life Benefits of More Frequent Home Hemodialysis:

• Due to the shorter post-treatment recovery time patients may gain a day or more of quality time per week.
• More control, freedom and flexibility with treatment scheduling. This means patients can fit dialysis into their lives, rather than fitting their life around treatment.
• Ability to travel without having to schedule in-center treatments along your route, with newer, portable machines.

Daily Home Hemodialysis (HHD)

Daily home hemodialysis (HHD) is not for everyone. It requires both a patient and partner who are committed to being trained on and following the guidelines for proper system operation.

If you choose to do daily home hemodialysis you must carefully follow your dialysis prescription, which may call for daily treatments up to six times per week. Each treatment can take about 2.5-3 hours or more including set up and tear down.

To be successful with home hemodialysis you must make sure you have a clean and safe place to do your treatments. You will also need to have space set aside in your home to store your supplies.

You and your partner will be responsible for tasks that would normally be taken care of by the in-center dialysis staff. You will perform all of the dialysis treatment tasks from start to finish, including setting up the machine and tubing, inserting the needles, responding to and solving all system alarms, and doing all of the clean up at the end of treatment. You will learn how to take your blood pressure, follow infection control procedures and how to follow the step by step instructions given to you by your training nurses. You and your partner will also be trained to respond to any health emergencies that might happen during treatment at home, including dizziness, nausea, hypotension (low blood pressure), and fluid or blood leaks.

Thousands of patients are performing daily HHD and enjoy the improved health, quality of life and freedom it provides.

HHD Glossary

A

Access: In dialysis, the natural or artificial blood vessel used to get blood in and out of the dialysis filter.

Adverse reaction: An unexpected and undesirable reaction to a drug or treatment that may be serious or life threatening.

Anticoagulation (ant- eye-KO-AG-you-lay-shun): The process of administering a substance, such as heparin, to prevent the blood from clotting.

Artery (AR-ter-ee): Blood vessels that carry blood away from the heart.

Arteriovenous (ar-TEER-ee-oh-VEE-nus) fistula (FIST-yoo-lah): Also called an AV fistula. Surgical connection of an artery directly to a vein, usually in the forearm, created in patients who will need hemodialysis.

Arteriogram: An X-ray of the arteries taken with the use of contrast dye; sometimes called angiography.

Artificial kidney: Another name for a dialysis filter or dialyzer.

Aseptic Technique (A-cept-ik Tek-neek): Practices that reduce the risk of infections.

B

Bacteria: Single cell organisms or "germs" that can cause infection or disease.

Bloodborne Pathogens: Organisms or "germs" that can live in the blood and can be spread to other people.

Blood Flow Rate (BFR): The volume of blood per minute flowing from and returning to the patient through the blood tubing and filter. Blood flow rate is measured in ml/min.

Bloodline: The tubing set that carried the blood from the patient to the HD machine and back to the patient.

Blood pressure: The force of blood exerted on the inside walls of blood vessels, expressed as a ratio (example: 120/80, read as "120 over 80").

Bolus: Giving a specific amount of IV fluid during dialysis. This is usually used to treat low blood pressure.

C

Catheter: A soft tube that is inserted into a large vein in the neck, chest, or leg to provide vascular access.

Chronic kidney disease (CKD): Damage of the kidneys from a variety of causes.

Convection: A process in which waste products are carried across a membrane or filter by the movement of fluid. This works kind of like a coffee maker.

D

Dehydration (dee-hy-DRAY-shun): The loss of too much body fluid through excessive urinating, sweating, diarrhea or vomiting.

Dialysis (dy-AL-ih-sis): The process of removing wastes and excess fluid from the blood artificially.

Dialysate: A special fluid mixture used to clean the blood during dialysis.

Dialyzer (DY-uh-LY-zur): The filter used in a dialysis system to remove wastes and fluid.

Diastolic (DY-uh-STAH-lik) blood pressure: The "bottom" number in a blood pressure reading (120/80), the blood pressure when the heart rests.

Diffusion (De-few-SHUN): Movement of waste products across a membrane or filter from a high concentration (the blood) to a low concentration (dialysate). This works kind of like making tea with a tea bag.

Disinfection (Des-in-Fek-shun): The process of cleaning to prevent the growth of bacteria that could lead to infection.

Dry Weight: The "ideal" weight for a person, at which blood pressure is normal and there is no swelling from extra fluid.

Dwell time: The amount of time dialysis solution remains in the patient's abdominal cavity during a peritoneal dialysis exchange.

E

Edema (eh-DEE-muh): Swelling caused by excess fluid and salt in the body.

Effluent: The filtered fluid containing waste products and excess fluid removed from the patient's blood.

Electrolytes (ee-LEK-troh-lites): Chemicals in body fluids including sodium, potassium, magnesium, and chloride.

End-stage renal (REE-nul) disease (ESRD): Total and permanent kidney failure.

Erythropoietin (eh-RITH-roh-POY-uh-tin): A hormone made by the kidneys that stimulates the body to make red blood cells.

F

Filter: See dialyzer.

Fistula (FIST-yoo-LAH): A connection created by surgery between an artery and vein to make a bigger blood vessel for dialysis access. The "gold standard" because it is easy to use, has low infection rates, and lasts a long time.

Fluid overload: A condition in which the body contains too much water and salt.

G

Graft: In hemodialysis, a vascular access surgically created using a synthetic tube to connect an artery to a vein.

H

Hemodialysis (HEE-moh-dy-AL-ih-sis): The process of using of a machine to remove wastes and fluid from the blood after the kidneys have failed.

Hypertension (HY-per-TEN-shun): High blood pressure.

Hypertensive (HY-per-TEN-siv): Having high blood pressure.

Hypotension (hy-poh-TEN-shun): Low blood pressure.

K

Kidney: One of two bean-shaped organs that filter wastes from the blood located near the middle of the back.

Kidney failure: Loss of kidney function.

M

Membrane: A thin sheet or layer of tissue that lines a cavity or separates two parts of the body, and that can act as a filter.

Modality (Mo-DAL-uh-tea): A type of treatment.

N

Nocturnal (Knock-turn-el): Happening at night, in dialysis this is treatment that it done at night while sleeping.

O

Oxalate: A chemical that combines with calcium in urine to form the most common type of kidney stone (calcium oxalate stone).

Over-The-Counter: Medications which can be sold and obtained legally without a doctor's prescription.

P

Phosphate: A substance in many types of foods.

Phosphate binders: Medication that helps prevent a build-up of phosphate in the blood.

Prescription (PRE-skrip-shun): A doctor's written orders; can be for medicines or treatments like dialysis.

R

Renal (REE-nul): Having to do with the kidneys.

Rinse back: Using sterile fluid to rinse the bloodline and dialyzer of all the blood after dialysis.

S

Semipermeable Membrane (Semi-purr-Me-abul Mem-brain): A natural or artificial membrane that aids in the separation of substances and fluids and allows only certain types of substances to move across it.

Stenosis: A narrowing of a blood vessel or other organ.

Systolic (sis-TAH-lik) blood pressure: The first number of a blood pressure (120/80) or the pressure when the heart pushes blood out into the arteries.

Support group: An organized network of people with something in common who give and receive help, advice, friendship and emotional support.

T

Toxin: Something that is poisonous.

U

Ultrafiltration (Ull-trah-fill-TRAY-shun): Removes fluid from the blood, if not replaced removes excess patient weight.

Ultrafiltration Rate (Ull-trah-fill-TRAY-shun): The amount of fluid, measured in liters or milliliters per hour, removed from the patient across the filter to reach dry weight goal.

Universal Precautions (You-ne-VERSE-al PRE-kaw-shuns): A way of preventing infection by treating all blood and body fluids as if they contained infection. See aseptic technique.

V

Vaccine: A serum containing weakened or killed germs that protect against infections.

Vascular (VASS-kyoo-lur) access: A natural or artificial blood vessel used to move blood into and out of a dialysis filter.

Vein (VANE): A blood vessel that carries blood toward the heart.

Resources

• U.S. Renal Data System, USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2008.
• Woods JD, et al. Comparison of mortality with home hemodialysis and center hemodialysis: a national study. Kidney International. 1996; 49:1464-1470.
• Blagg CR, et al. Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio. Hemodialysis International. 2006; 10:371-374.
• Agar J, et al. Comparing the relative survival of an Australian nocturnal home HD cohort with a matched USRDS conventional HD cohort using Standardized Mortality Ratios. American Society of Nephrology. 2007; abstract presented at ASN 2007 Annual Congress, October 31, 2007.
• Kjellstrand C, et al. Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years. Nephrol Dial Transplant. 2008; 23:3283-3289.
• Ayus J, et al. Effects of SDHD vs CHD on LVH and Inflammatory markers. J Am Soc Nephrol 16: 2778-2788, 2005.
• Fagugli R, et al. SDHD: Blood pressure control and LVM reduction in hypertensive HD patients. Am J Kidney Dis Vol 38, No 2 2001 371-376.
• Culleton B, et al. Effect of Frequent NHD vs CHD on Left Ventricular Mass and Quality of Life. JAMA 2007. Vol 298, No. 11, 1291-1299.
• Finkelstein F, et al. Daily home HD (DHD) improves quality of life (QOL) measures, depressive symptoms and recovery time: Interim results from the FREEDOM study. Abstract presentation at the American Society of Nephrology 2008 Annual Congress.
• Finkelstein F, et al. Daily hemodialysis improves depressive symptoms at 12 months of follow-up: Interim results from the FREEDOM study. Hemodialysis International. 2009;13(1):111.
• Finklestein F, et al. Depression and end-stage renal disease: a therapeutic challenge. Kidney International. 2008;74:843-845.
• Lopes AA, et al. Screening for depression in hemodialysis patients: associations with diagnosis, treatment, and outcomes in the DOPPS. Kidney International. 2004; 66:2047-2053.
• Kimmel PL, et al. Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney International. 2000; 57:2093-2098.
• Lopes AA, et al. Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney International. 2002; 62:199-207.Mapes DL, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney International. 2003; 64:339-349.
• Finkelstein F, et al. Daily home HD (DHD) improves quality of life (QOL) measures, depressive symptoms and recovery time: Interim results from the FREEDOM study. Abstract presentation at the American Society of Nephrology 2008 Annual Congress.
• Chan C. Cardiovascular Effects of Home Intensive Hemodialysis. Adv Chronic Kidney Dis Vol 16, No 3  2009 173-178.
• Kraus M, et al. A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease. Hemodialysis International 2007; 11:468-77.
• Jaber BL, et al. Daily hemodialysis (DHD) reduces the need for anti-hypertensive medications. Abstract presentation at the American Society of Nephrology 2009 Annual Congress.
• Finkelstein F, et al. Daily home HD (DHD) improves quality of life (QOL) measures, depressive symptoms and recovery time: Interim results from the FREEDOM study. Abstract presentation at the American Society of Nephrology 2008 Annual Congress.
• Mapes DL, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney International. 2003;64:339-349.
• Goldfarb-Rumyantzev A, et al. A crossover study of short daily haemodialysis. Nephrol Dial Transplant. 2006. 21:166-175.
• Kraus M, et al. Work and Travel in a Large Short Daily Hemodialysis (SDHD) Program. Abstract presentation at the American Society of Nephrology 2007 Annual Congress.
• NxStage Summary of Literature: Benefits of Daily Dialysis Booklet. 
• World Health Organization (WHO). Definition of Palliative Care. Retrieved from http://www.who.int/cancer/palliative/definition/en/ [3].