By Christopher Blagg, MD

Home hemodialysis is carried out in the patient’s home by the patient or with assistance from a family member or other helper. First developed in Boston , London and Seattle in the early 1960’s, home hemodialysis was soon found to be a safe, effective and economical way of providing dialysis. By 1972, of the 10,000 or so patients on dialysis in the United States , more than 4,000 were being treated at home.

Why is home hemodialysis good for patients? First, evidence from research studies show that home hemodialysis patients live longer than patients treated in a dialysis center. There is also good evidence that the quality of life for these patients is better. These benefits are important, but there are others. In Seattle , it was first noticed in the 1960’s that home hemodialysis patients became more independent and self-sufficient. It was also observed that the more patients knew about their disease and the more responsibility they took for their own treatment, the better their quality of life resulted. These factors apply not only to end-stage renal disease (ESRD) patients, but also to those with any chronic disease – a concept that is being researched today.

Other advantages of home hemodialysis include:

• A greater opportunity for rehabilitation, including work or education

• The opportunity to perform longer dialysis, even overnight dialysis

• Access sticking by one person, either by patient or assistant

• The flexibility to dialyze at times convenient for the patients, saving in travel time and hassle

• Not having to dialyze in the center with sick patients and with risk of exposure to infections, such as hepatitis C

• And finally, the feeling of accomplishment

What are the disadvantages of home hemodialysis? These are primarily psychological rather than medical. The most common is “burn out” of the family member or assistant. This is why it is crucial to emphasize the importance of patients taking care of themselves. The home program can also arrange for patients to dialyze in-center to allow time-off or vacation for the assistant. Although there may be individual disadvantages, there are many patients who have carried out home hemodialysis successfully for years.

What is needed for home hemodialysis? First and most obvious is a willing patient with a home having adequate space for the equipment and storage of supplies. There must be suitable electrical outlets and plumbing to make the dialysate and to drain the machine. The home hemodialysis training program will check these requirements before accepting the patient. It is important that the patient be trained to stick themselves and to dialyze themselves. However, in many cases when using standard dialysis equipment, a family member or other aide may be required. 

What about home hemodialysis training? This takes anywhere from three weeks to three months, depending on the training program and the abilities of the patient. The training is usually carried out in the outpatient setting. Patient and helper are tested throughout the training process to ensure that they can perform safe dialysis, have knowledge of how to handle problems with equipment and during emergency situations and how to get support by telephone or modem in order to deal with questions and non-emergency situations.

Is it difficult to learn to do your own dialysis? Not particularly. Do not be overwhelmed by the complicated looking machine. If you can drive a car safely, you can certainly learn to operate a dialysis machine equally well. In neither case do you need to know the details of what is under the hood or in the machine. Rather, you have to learn how to use the device safely. Remember, most ordinary people can learn to drive with appropriate training and the same applies to dialysis.

What happens after the patient goes home? The patient will be expected to send information about each dialysis session to the training unit either by filling out a form or by direct electronic connection. Once a month, the patient will be expected to provide a blood sample for the usual tests. The patient is expected to see the nephrologist at least monthly in the physician’s office. There will be a training nurse available by telephone at all times who can answer questions, assist the patient in dealing with problems, arrange for technical support for the machine if needed and advise the patient to contact their nephrologist if necessary or to go to the emergency room for acute problems. It is also likely that a training nurse will visit you at home at least once a year to advise and observe dialysis sessions. You will be expected to give your own erythropoeitin (EPO) injections, but you will have to come in to the center or the physician’s office for other intravenous (IV) injections.  

Who pays for home hemodialysis? Medicare pays in just the same way that it pays for center dialysis. Private insurance, Medicaid or state programs will usually pick up most of the co-insurance costs. The primary individual costs will be for additional electricity and water required for dialysis, and in some areas these costs may be subsidized by a city or utility company.

What does the future hold for home hemodialysis? There will be more of it! There is good evidence that longer dialysis and/or more frequent dialysis is better. In the United States , the average in-center patient dialyzes less than four hours for three times a week and, despite lots of efforts over the last ten years, patient survival has not improved. A few programs provide six to eight hours of dialysis overnight three times a week, but there is still a great lack of home hemodialysis programs in this country.

Studies have shown that dialyzing five, six and even seven times a week improves patient well-being remarkably, minimizes symptoms both during and between dialyses and reduces the frequency of complications and of days in a hospital. More frequent dialysis can be done by short daily dialysis for two to three hours or long nightly dialysis for six to eight hours – and the most convenient place to perform either of these treatments is at home. Currently, home hemodialysis at least three times a week remains the best treatment for patients who are willing to do this.

What should you do? Hopefully this article has raised your interest in home hemodialysis. Talk to AAKP, your local patient organization or the ESRD Network in your region and ask to be put in touch with patients who are on home hemodialysis. Talk to them about their experience. It will require interested patients like you to ask your doctor and your unit how you could get home hemodialysis. Home dialysis could become a reality for many more patients over the next few years. Currently, dialyzing overnight provides the best treatment available for dialyzing three times a week. For nightly dialysis, every other night might be better. Remember, regardless of which treatment you choose, you have the option to take charge of your healthcare.

Dr. Blagg is the Executive Director Emeritus of the Northwest Kidney Centers and Professor Emeritus of Medicine at the University of Washington . He also serves as a member of AAKP’s Medical Advisory Board.  

This article originally appeared in the March 2003 issue of aakpRENALIFE Vol. 18, No. 5.

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