By Robert S. Lockridge, Jr., MD

Thirty-five years ago, the standard frequency for dialysis in the United States was set at three times per week. The duration of dialysis sessions has been decreasing over the past thirty years, so the patient today averages three and one-half hours to four hours per treatment. The renal community developed the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF/DOQI) guidelines as a standard of care for patients on dialysis. The renal network, which works with Centers for Medicare and Medicaid Services (CMS) and the renal community, has supported the quality of care standards set forth by NKF/DOQI. However, patients with end-stage renal disease (ESRD) still have a yearly mortality rate of about 20 percent, and only 25 percent of patients requiring dialysis age 18 to 55 are employed. Quality of Life Survey (SF36) scores suggest that ESRD patients do not feel physically or emotionally well because of their chronic disease state. Nightly Home Hemodialysis (NHHD) and Short Daily Dialysis (SDD), supported by over 300 articles in the medical literature, suggest that these outcomes can change for ESRD patients. Below is a description of the what, who and how of NHHD.

History of NHHD

The history of NHHD dates back to the early 1960s when Stanley Shaldon, MD, in London reported patients dialyzing at home, overnight, three times per week. Belding Scribner, MD and others also dialyzed patients at home overnight three times per week in the United States in the 1960s and early 1970s. It was not until the 1990s, when Robert Uldall, MD, a nephrologist practicing in Toronto, Canada, thought that a slower, longer, gentler daily dialysis would be better for the dialysis patient and introduced daily nocturnal dialysis. He and his team applied for a grant from the Health Minister of Ontario to start a nocturnal program in 1994. The grant was approved, and the program was started. Dr. Uldall died unexpectedly in 1995. Andreas Pierratos, MD and the nocturnal team continued the Toronto nocturnal program. In 1997, Dr. Pierratos presented data on thirteen patients' experiences at the International Symposium on Home Hemodialysis in Denver. The Toronto nocturnal team was able to show that this new modality was safe and beneficial for ESRD patients.

Method and Requirements for NHHD

NHHD is performed five, six or seven times per week at night while the patient sleeps. Dialysis accesses for the NHHD patient are dialysis catheters, AV fistulas or AV grafts. The blood flow rates are 200 ml/min to 300 ml/min, and the dialysate flow rates are 200ml/min to 300ml/min. Heparin, is used to prevent the artificial kidney from clotting. The standard in-center machine is used. The water source for the machine can be well water, spring water, or city or county water. The water is treated with either a Reverse Osmosis system (RO) or a Deionizer system (DI) to assure safe water for dialysis. The electrical requirement for the machine is a 110-volt dedicated line. The machine requires a drain line that can be connected to any drain in the home. Patients have done NHHD in houses, mobile homes and apartments. A standard, single door closet can sufficiently store the required monthly supplies.

Who is Doing NHHD?

Patients whose ages range from twenty to eighty, males and females, seventh grade-educated to college-educated people and all ethnic groups are currently benefiting from NHHD. Some patients perform the treatment alone while others have partners. There are about ten centers each in the United States and in Canada offering the new modality of NHHD to their patients. There have been over 100,000 treatments performed at home by patients in the USA and Canada.

The Advantages and Disadvantages of NHHD

The advantages of NHHD are numerous and well documented in the medical literature. These advantages include empowerment of the patients in directing and controlling their healthcare, improvement in the patients' well being during and after treatments as documented by increases in their SF36 scores, elimination of phosphate blinders, 75 percent reduction of blood pressure medications, improvement in sleep disorders and improved dietary intake. This new modality has also shown a reduction in hospitalizations as well as a reduction in EPO usage. Once on NHHD, the patient sleeps, so this is not considered "dialysis time" by the patient.

One disadvantage of this new modality, using the present technology, is that the training process takes an average of six weeks and is difficult to learn. Additionally, not all patients can perform this new modality at home due to physical limitations. Hopefully, with new developing technology, this will improve. The use of central dialysis catheters, AV fistulas and grafts present the usual concerns of infection and venous disconnection. To date, dialysis centers performing NHHD have not reported any significant access problems, although this remains a concern. Before considering NHHD, please consult your physician regarding his or her thoughts of the advantages and disadvantages of this modality.

What is Preventing NHHD from Happening in the USA?

There are several issues that prevent NHHD from happening. Most patients are unaware of this new modality and its benefits. Many nephrologists and dialysis nurses are not trained in the modality. The technology for NHHD, at present, is in-center technology, rather than technology developed for daily home hemodialysis. Over the past five years, the industry has been in the process of developing this new technology. The major problem that prevents this modality from being offered to the patient appears to be the reimbursement polices of the Centers for Medicare and Medicaid Services (CMS).

How Can NHHD and Short Daily Dialysis Become an Option for ESRD Patients?

Patients who have experienced the benefits of daily dialysis and patients who know about this new modality must educate other patients concerning this option. Physicians and nurses who know about this modality must educate other dialysis professionals concerning the benefits of this modality. The dialysis industry must continue to invest in new technology for this modality in order to make it available to the ESRD patients. CMS and Congress need to develop reimbursement methods that will fairly support NHHD.

Congressman Jim McDermott of Washington recently introduced HR1004, the "Kidney Patient Daily Dialysis Quality Act of 2003." This bill recognizes daily dialysis, defined as five or more treatments at home or in-center, short or long, as a new modality. It states that the patient and the physician will decide if the treatment would benefit the patient. It instructs the secretary of CMS to develop an appropriate reimbursement method and work with the nephrology community to develop standards of care for this modality. This will be the beginning of offering this option of higher quality of care for ESRD patients.

Dr. Lockridge is Medical Director of Home Dialysis at Lynchburg Nephrology Dialysis Inc., Lynchburg, Virginia. 

This article originally appeared in the May 2003 issue of aakpRENALIFE Vol. 18, No. 6.

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