Home Preparation and Installation for Home Hemodialysis

Introduction

Home hemodialysis has been available as a modality of kidney replacement therapy since the 1960s. The interest in home hemodialysis has been increasing over the past years because of its flexibility and benefits (which will be further discussed in the following section). Historically, home hemodialysis accounted for about 40% of the dialysis population in the United States in the 1970s and decreased in popularity in the 1980–90s. It is currently experiencing a resurgence in several countries, especially with the interest in more frequent or intensive hemodialysis. The U.S. Renal Data System (USRDS) 2019 Annual Data Report indicates that 62.7% of all prevalent dialysis patients were receiving in-center hemodialysis. Among the prevalent patients treated with hemodialysis, 2.0% used home hemodialysis.

Basis for Home Hemodialysis

Home hemodialysis offers several potential benefits as compared to conventional facility-based hemodialysis. These include better patient outcomes, increased freedom of time, cost reduction, as well as an improved quality of life. Improvements in patient outcomes with more frequent or intensive home hemodialysis include better survival, blood pressure control, left ventricular geometry, phosphate control and mineral metabolism, quality of sleep, and fertility. Home hemodialysis offers more control from a patient's perspective over dialysis treatment scheduling and may afford greater flexibility in terms of employment. As compared to facility-based hemodialysis, home hemodialysis is cost-effective or cost-saving due to lower staff costs and likely medication costs. It may have better health outcomes in kidney disease–related quality of life and survival.

Requirements

There are several prerequisites that need to be addressed before commencing a home hemodialysis program. A home visit should be conducted prior to further discussion of home dialysis to determine its feasibility and assess the necessary modifications. The availability of a checklist for the home visit may facilitate the process ( Table 14.1 ).

Table 14.1

Home Hemodialysis Initial Home Assessment Record

Checklist (to circle appropriately)
Plumbing
Water source	Well	City	Others
Water conductivity
Total chlorine
Type of piping material used in plumbing
Water pressure (psi) in home
Source of water to RO	Wash room	Basement	Others
Type of drain pipe	ABS	Copper	Cast iron	Others
Drainage to city or septic system	Flow open		Flow closed
Can system above handle RO and machine reject water	Yes		No
Electrical
Space available on breaker panel	Yes		No
Type of panel (name)
Storage space
Appropriate area selected for storage	Yes		No
Area free of pest infestation	Yes		No
Dampness/water damage present	Yes		No
Room for stock rotation	Yes		No
Adequate space for dialysis room	Yes		No

ABS , acrylonitrile-butadiene-styrene; RO , reverse osmosis.

There are multiple domains of requirements, including the following.

Legal

The local legal requirements regarding water supply, as well as land and housing, should be established to ascertain if home hemodialysis is feasible. There should be no legal restriction to the use of the building for the purpose of home hemodialysis. In addition, legal requirements concerning waste disposal, sewage, and electrical supply should also be established before the consideration of home hemodialysis. Consideration should be given toward specific policies regarding potentially biohazardous waste.

A unit policy should ideally be in place to decide who is financially responsible for the needed modifications to the home that may be necessary for plumbing and/or electrical renovations.

Water Preparation, Standards, and Plumbing

Home hemodialysis, as compared to conventional in-center hemodialysis, is potentially a more water-intensive procedure, with larger volumes of water being necessary to reconstitute the dialysate (except for the mobile platform). The total dialysate volume can range between 110 and 150 L for a 6- to 8-hour session of dialysis, as compared to 120 L for a typical conventional session. This makes water preparation and quality measurement critically important.

The water supply can come from various sources, for example, municipal water and feed water. Various water quality standards exist depending on where the dialysis is performed (International Organization for Standardization [ISO], Association for Advancement of Medical Instrumentation [AAMI]; Table 14.2 ), and the prevailing standards should be adhered to. It is important for a full chemical analysis of the water for dialysis to be conducted to determine the degree of water purification necessary.

Table 14.2

Water Quality Standards for Dialysis Water ^⁎

Microbiologic Level
	AAMI	ISO
Dialysis Water
Colony-forming units (CFU)	< 100 CFU/mL	< 100 CFU/mL
Endotoxin units (EU)	< 0.25 EU/mL	< 0.25 EU/mL
Ultrapure water
Colony-forming units (CFU)	< 0.1 CFU/mL	< 0.1 CFU/mL
Endotoxin units (EU)	< 0.03 EU/mL	< 0.03 EU/mL

⁎ Data from AAMI (Association for the Advancement of Medical Instrumentation) 13959:2014 and ISO (International Organization for Standardization) 13959:2014.

The plumbing system modifications should also take into consideration the level in the home in which the dialysis is done. Should dialysis take place on higher floors, additional components, for example, pump systems and feeder tanks, may be needed to provide the necessary water pressure for the reverse osmosis unit and dialysis machine to function properly, as appropriate.

Depending on the local water conditions and regulations, other modifications like backflow preventers and blending devices may also be necessary.

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