The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial.

Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/V(urea), a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Thus, we were unable to demonstrate a definitive benefit of more frequent nocturnal hemodialysis for either coprimary outcome.

Recruitment and training for home hemodialysis: experience and lessons from the Nocturnal Dialysis Trial.

BACKGROUND AND OBJECTIVES: We assessed perceived barriers and incentives to home hemodialysis and evaluated potential correlates with the duration of home hemodialysis training. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: Surveys were sent to the principal investigator and study coordinator for each clinical center in the Frequent Hemodialysis Network Nocturnal Trial. Baseline data were obtained on medical comorbidities, cognitive and physical functioning, sessions required for home hemodialysis training, and costs of home renovations. RESULTS: The most commonly perceived barriers included lack of patient motivation, unwillingness to change from in-center modality, and fear of self-cannulation. The most common incentives were greater scheduling flexibility and reduced travel time. The median costs for home renovations varied between $1191 and $4018. The mean number of home hemodialysis training sessions was 27.7 +/- 10.4 (11-59 days). Average training time was less for patients with experience in either self-care or both self-care and cannulation. The number of training sessions was unrelated to the score on the Modified Mini Mental Status or Trailmaking B tests or patient's education level. Training time also did not correlate with the SF-36 Physical Function subscale but did with the modified Charlson comorbidity score and older patient age. CONCLUSIONS: Lack of patient or family motivation and fear of the dialysis process are surmountable barriers for accepting home hemodialysis as a modality for renal replacement therapy. Formal education and scores on cognitive function tests are not predictors of training time.

Short and long nightly hemodialysis in the United States.

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.

Nightly home hemodialysis: five and one-half years of experience in Lynchburg, Virginia.

BACKGROUND: Lynchburg Nephrology Dialysis Incorporated initiated a nightly home hemodialysis (NHHD) program in September 1997. As of April 30, 2003, 40 patients had completed training; 28 patients were at home and 2 patients were in training. The average age of the patients at the initiation of the home-based therapy was 50 years, with a range of 23 to 81 years. There have been 24,239 treatments at home with a total of 84.86 patient-years on NHHD, the longest patient for 66.7 months and the shortest for 1 month. METHODS: Patients dialyzed using the Fresenius 2008H machine, 6 to 10 hr, 5 to 6 nights per week. Treatment parameters included a blood flow rate of 200 to 250 mL/min; a dialysis flow rate of 200 to 300 mL/min; and a standard dialysis solution with 2.0 mEq/L potassium, 3.0 to 3.5 mEq/L calcium concentrations, 35 mEq/L HCO(3), and 140 mEq/L sodium. The longitudinal data of each patient in the program for 1, 2, 3, 4, and 5 years were compared to the same patient's pre-NHHD data. There were 25 patients in the program for 1 year, 19 patients for 2 years, 14 patients for 3 years, 6 patients for 4 years, and 4 patients for 5 years. RESULTS: Statistically significant improvement occurred in all five groups' need for antihypertensive medications and phosphate binders, SF36 scores, calcium/phosphorus product, blood pressure, number of hospital admissions, and number of days of stay in the hospital. The mortality rate was 2.4% deaths per patient-year with a 95% confidence interval of 0.9% to 9.4%. CONCLUSIONS: In a longitudinal study, NHHD showed significant improvements in patient secondary outcomes. The improvement in these secondary outcomes was associated with an improvement in mortality rate.

Six years of experience with nightly home hemodialysis access.

BACKGROUND: Lynchburg Nephrology Dialysis Incorporated started its nightly home hemodialysis (NHHD) program in September 1997. PURPOSE: The purpose of this study was to evaluate episodes of exit-site infections, catheter sepsis, and safety and longevity of accesses for patients doing NHHD. METHOD: If internal jugular (IJ) catheter was chosen, the patient was started on 2 mg coumadin per day when catheter was placed. If catheter malfunctioned, it was blocked with a thrombolytic agent and coumadin was adjusted to meet a goal international normalized ratio (INR) of 1.5 to 2.25. If the problem persisted, the catheter was exchanged. For catheters, a threaded lock cannula (BD InterLink device, BD) was used to prevent air emboli and infections and a locking device was used to prevent disconnects. If arteriovenous (AV) fistula was used, four buttonholes were established using 16-gauge needles. If AV graft was used, patients were taught the rope ladder cannulation technique using 16-gauge needles. RESULTS: As of September 1, 2003, 45 patients have completed training and have performed 27,063 treatments at home. Total catheter time at home was 930 months. Total AV fistula and AV graft times at home were 190 and 20 months, respectively. Upon completion of training, 34 patients were using tunneled IJ catheters, 10 were using AV fistulas, and 1 was using an AV graft. The IJ catheter exit-site and sepsis infection rates were 0.35 and 0.52 episodes per 1000 patient-days, respectively. Mean catheter life was 8.5 months with the longest being 66.7 months and the shortest being 0.2 months. The AV fistula and graft exit-site and sepsis infection rates were 0.16 and 0 episodes per 1000 patient-days, respectively. Catheter complications included one episode of disconnect due to patient's failure to use the locking device, one episode of central stenosis, and one episode of intracranial hemorrhage, due to prolonged INR, with resolution of symptoms. CONCLUSION: Data support the fact that tunneled IJ catheters, AV fistulas, and AV grafts are effective and safe permanent accesses for patients on NHHD.