(Disclaimer: Feeling nauseated may also indicate you are not receiving enough dialysis. Talk to your doctors about your URR and Kt/V to learn more.)

Nocturnal hemodialysis or nightly hemodialysis is a form of hemodialysis which is done at home by the patient or a family member when the patient is sleeping at night. Most patients dialyze three or four nights a week, anywhere from six to12 hours, on average for eight hours.

How is nocturnal hemodialysis different than other forms of dialysis?
It is twice as long and twice as frequent as conventional hemodialysis. Therefore, nocturnal hemodialysis offers better cleansing of the blood of wastes, salt and water (two to four times as much). It is the closest method to normal kidney function. Furthermore, dialysis in the home offers more freedom and doing it at night leaves the day free for other activities.

Do the patients feel a difference?
Many patients do feel much better. Many of the symptoms caused by the lack of kidney function such as nausea, vomiting, shortness of breath, itchiness, dry skin, tiredness, lack of energy disappear. The mind clears. Appetite and ability to taste improve. Sexual drive and function also improve. Symptoms related to hemodialysis itself also improve dramatically. Muscle cramps, low blood pressure during dialysis and exhaustion after dialysis are no longer present. Patients do not have to rest or go to sleep after dialysis to recover.

What are some other benefits?
Blood pressure control improves so much that some patients stop their blood pressure pills within the first few weeks after starting nocturnal hemodialysis. Additionally, the amount of erythropoietin (EPO) the patients need decreases in most patients and some come off this red blood cell booster drug altogether.
Sleep patterns improve. In patients with the sleeping disorder ‘sleep apnea’ (loud snoring with brief periods when breathing stops during sleep), nocturnal hemodialysis has been shown to improve this problem. Patients report sleeping soundly and waking up refreshed, after adjusting to the dialysis machines after a few weeks. Several studies over the last few years have shown the function of the heart and the blood vessels improves on nocturnal hemodialysis.

Who is suited for nocturnal hemodialysis?
Generally, patients who are committed and able to learn how to do hemodialysis at home can choose nocturnal hemodialysis. It is estimated that 20-40 percent of all dialysis patients can do it. Alternatively a family member or a paid helper can be trained to perform the dialysis. Of course one needs adequate space at home for the machine and the supplies.

Can diabetics or patients with severe heart disease be on nocturnal hemodialysis?
Yes, some. Diabetic patients and patients with other serious conditions can be on nocturnal hemodialysis and often benefit even more than patients who do not have problems other than kidney disease.

Do I need a special kind of dialysis machine?
No. Any dialysis machine can be used. Several machines have been modified or were created to be easier for use at home Some dialysis centers provide ‘live’ monitoring of the dialysis machines by a telephone or internet connection. If there is an alarm at home, the patients are called if they are not awakened by the alarm. This monitoring is not a critical part of nocturnal hemodialysis and patients can dialyze safely without monitoring as long as they follow the instructions that they have been taught during the training.

What renovations do I need at home?
Minor renovations at home include a drain for the dialysis fluid and a dedicated electricity plug. Some machines may not need these changes. The cost of the renovations is about $500-750. Extra monthly cost for electricity and water may be necessary for most of the dialysis machines ($50-70 per month). Ask your program if you would be responsible for this expense.

What about problems sleeping while connected to a machine?
Even with some noise from the dialysis machine and water system, most patients have no trouble sleeping after the first few nights. Spouses also report getting use to the background sounds. Some patients reported they had trouble relaxing and falling into a deep sleep during dialysis even several weeks after starting the treatment.

Do I have to dialyze every night?
Some patients are on nocturnal hemodialysis every other night (or three nights a week). This type of dialysis can be done either at home or at the dialysis facility. This method is less efficient but is still much better than the traditional dialysis three times a week and represents a desirable option especially if the nightly nocturnal hemodialysis cannot be offered for financial reasons. There are some diet restrictions and some patients still need to take phosphate binders.

Can I return to work?
Yes. Many nocturnal hemodialysis patients have returned to work either part or fulltime. By dialyzing at night, they have daytime freedom to do the activities they choose and because they feel better they have the energy to work.

What about dialysis vascular access?
Any dialysis access is good for nocturnal hemodialysis. Central venous catheters, fistulas and grafts have all been used successfully. Since the dialysis takes place during sleep, it is important that adequate precautions are taken to prevent an accidental disconnection that could be life threatening. Proper taping and anchoring of the needle or use of a slightly modified way to connect to the catheter makes the connection stable.

What is the “buttonhole” technique?
The buttonhole technique for fistula cannulation includes putting the needle through exactly the same hole every time. This makes the success of the cannulation predictable and after a few cannulations, there is no pain involved. It is important to be extra careful to avoid infections when the buttonhole technique is used.

What about the “single needle system”?
The single needle system requires only one needle to perform hemodialysis. The blood flow through the needle changes direction every few seconds. This method cannot deliver high blood flow for the three times a week dialysis, but it is adequate for nocturnal hemodialysis, with its long duration and high frequency.

What about catheters?
Central venous catheters provide adequate flow for nocturnal hemodialysis, but often are inadequate for conventional hemodialysis. The use of catheters has been associated with more infections and more clots and is less preferable than the fistulas. To prevent catheter clotting, some patients take a blood thinning pill which can pose the risk of excessive bleeding. Some patients have had a very successful experience using catheters for a prolonged period of time.

What does the training involve?
Training usually lasts for six weeks. The patient comes to the training unit usually four to five days per week for five to six hours each day. The patients learn not only the dialysis technique but also how to take blood samples and give intravenous medications. If the patient has previous experience with hemodialysis, the training period is shorter.

What are the risks?
The main risk of nocturnal hemodialysis is the disconnection of the dialysis tubing from the access. This can be a serious problem if it is not dealt with right away. Machine alarms as well as proper taping of the needle, and finally the use of the so called ‘enuresis alarm’ make the method reasonably safe. The enuresis alarm is a moisture sensor that is taped on top of the dialysis needle and alarms if there is even a small blood leak. The question of “over-dialysis” has been raised. The concern is that too much dialysis can remove “useful” chemicals. To date, there has been no information to justify this fear.

Why is nocturnal hemodialysis not used more widely?
Programs have been started in Canada (initially in Toronto in 1994), the United States, Australia, and several countries in Europe. The main obstacle now is cost for the dialysis units. Dialysis providers have to pay for the cost of the more frequent hemodialysis. They usually pay for dialysis three times a week. However, nocturnal hemodialysis saves money to the system as the patients stay healthier, do not have to be in the hospital and use fewer medications. More studies are needed to prove that nocturnal hemodialysis provides high quality dialysis at a reasonable cost. A study has started to compare patients on nocturnal hemodialysis to patients who stay on regular hemodialysis. This study is sponsored by the National Institutes of Health (NIH) and the Centers for Medicare and Medicaid Services (CMS).

If you need more information talk to your nephrologist or visit www.homedialysis.org.

References:
1. Pierratos A, Harrington JT, Strom J, Perrone RD, Narayan G, Levey AS, et al. Daily nocturnal home hemodialysis. Kidney International 65[5], 1975-1986. 2004.
2. Heidenheim AP, Muirhead N, Moist L, Lindsay RM. Patient quality of life on quotidian hemodialysis. Am.J Kidney Dis. 42[1 Suppl], 36-41. 2003.
3. Mucsi I, Hercz G, Uldall R, Ouwendyk M, Francoeur R, Pierratos A. Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis. Kidney Int. 53[5], 1399-1404. 1998.
4. Hanly PJ, Pierratos A. Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal hemodialysis. The New England Journal of Medicine 344[2], 102-107. 11-1-2001.
5. Kundhal K, Pierratos A, Chan CT. Newer paradigms in renal replacement therapy: will they alter cardiovascular outcomes? Cardiol.Clin 23[3], 385-391. 2005.
6. Lockwood D. Why I like nocturnal dialysis. Nephrol News Issues 20[2], 48-49. 2006.
7. Twardowski ZJ, Harper G. Buttonhole method of needle insertion into arteriovenous fistulas. http://www.hdcn.com/symp/homehd/harper.htm . 1997.
8. Leitch RE, Ouwendyk M. Patient training and education. Contrib.Nephrol. 145, 39-47. 2004.

Dr. Andreas Pierratos is an associate professor of medicine at the University of Toronto. He directs the nocturnal hemodialysis program in the Humber River Regional Hospital in Toronto.
Dr. Sophie Kwok is a first year internal medicine resident at the University of Illinois College of Medicine at Peoria.

This article originally appeared in January 2007 aakpRENALIFE, Vol. 22, No. 4.

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