Home dialysis - Clinical Tree

1. What is home hemodialysis (HHD)?

HHD is a kidney replacement modality for patients with end-stage kidney disease (ESKD) that can be performed safely in the patient’s home environment. Assistance of a trained caregiver or qualified hemodialysis nurse is a requirement. The frequency of treatment for HHD can vary per individual patient. HHD can be performed as conventional HHD, with treatments 3 days a week for 3 to 4 hours or longer each time. It can also be performed as short daily HHD, occurring 5 to 7 times a week for shorter duration. Lastly, it can be performed overnight as nocturnal NHHD where treatments normally last 6 to 8 hours.

2. How many people today use HHD?

The 2010 United States Renal Data System (USRDS) report showed that 0.51% of incident dialysis patients were undergoing HHD. Based on the 2015 USRDS report, the use of HHD by incident ESKD patients increased by 222% from 2007 to 2013. Even with the large relative rise in HHD, its overall utilization as a home dialysis modality is significantly lower than that of peritoneal dialysis (PD). Home dialysis, either HHD or PD, was utilized by 9.1% of all patients undergoing dialysis as of 2013.

3. What machines are used for HHD?

In the United States HHD is performed with a “low-flow systems” (L-FS) machine. The most frequently used L-FS machine in the United States is the NxStage System. The NxStage machine is portable; it weighs 32 kg (71 lbs) and is 15 × 15 inches. Dialysate for the machine is provided in two ways. Delivery of 5-L dialysate bags can be made to a patient’s home, with four to six bags needed for short daily dialysis. These bags are convenient when patients are traveling. Alternatively, there is a fluid generator (PureFlow) that can prepare up to 60 L of dialysate (enough for two to three treatments) using a filtering system within the machine and connection to a tap water source.

4. How is HHD technically performed when compared with conventional hemodialysis?

The common conventional in-center dialysis machine is a “single-pass system” (SPS) machine. A SPS machine produces dialysate within the machine by proportionally mixing acid and base concentrates with a purified water source. The dialysate then moves as a single-pass, high-flow fluid to the dialyzer for transmembrane contact with the patient’s blood. A SPS machine typically uses a dialysate flow to blood flow (Qd:Qb) ratio of 2:1. With an L-FS machine (like the NxStage), the flow rates are reversed so that Qd:Qb is between 1:2 and 1:3. This permits a more complete equilibrium between dialysate and patient’s blood, ultimately allowing for the use of less dialysate.

5. What type of access is used for HHD?

Patients are able to use a tunneled central venous catheters (CVCs) or arteriovenous fistulae (AVF) to connect themselves to an HHD machine. As in conventional in-center hemodialysis, an AVF is preferred over a CVC, given the increased risk of blood stream infections associated with CVCs.

6. Describe the “buttonhole” method and why it is used.

The conventional method of repeated cannulation of an AVF involves using sharp-tip needles and rotating needle puncture sites (“rope-ladder technique”) with each successive dialysis treatments. A “buttonhole” is a constant fibrous tract established by repeated puncture followed by small eschar formation of the same site. Recannulation of the same two sites eventually allows access with a blunt-tip needle.

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