Home Hemodialysis

Hemodialysis (HD) is a life-preserving treatment for hundreds of thousands of Americans with kidney failure. But the standard schedule of in-center HD three times a week is, at best, inconvenient, and at worst, hard on the heart.

People who receive in-center HD travel to the clinic three times a week and sit in a chair for 3 to 4 hours each time while their blood is cleaned. Waiting for needle sites to stop bleeding and blood pressure to return to normal takes even more time. In-center HD patients must follow a strict schedule because the clinic treats three to five shifts of patients in the course of the day. Someone who gets to the clinic late often can't make up the time by staying longer because the machine is needed for the next patient.

Between treatments, in-center HD patients must limit drinking fluids to avoid gaining too much weight and raising their blood pressure. The standard HD diet also restricts phosphorus, salt, and potassium. The patient may have to take several drugs to control blood pressure and other problems like anemia and high phosphorus levels. Many people who dialyze three times a week complain of feeling exhausted or "washed out" for a few hours after a session. In the course of a week, the HD patient may feel highs and lows as the body builds up fluid and wastes and then has them washed away during treatments.

In recent years, many people have found that doing HD at home has many benefits. New dialysis machines are smaller and easier to use, making home HD more practical. Some machines may require special wiring or plumbing changes in the home, but others use standard household outlets. The home must have room for the HD machine, supplies, and in some cases a water purification machine.

How does home HD work?

A small but growing number of clinics offer home HD in addition to standard HD treatments. The patient starts learning to do treatments at the clinic, working with a dialysis nurse. Most people who do home HD have helpers who train with them at the clinic. The helper can be a family member, neighbor, or close friend. Some programs do not require a helper if the patient can do all the tasks alone.

The clinic will provide a machine for use in the home or help the patient get a machine from a supplier. The patient does not have to buy the machine. Supplies, such as dialysis solution, will be delivered to the home once or twice a month.

During training, the patient learns to

  • prepare equipment and supplies
  • place the needle in the vascular access
  • monitor the machine
  • check blood pressure and pulse
  • keep records of the treatments
  • clean the equipment and the room where dialysis is done
  • order supplies

Training often takes 3 to 8 weeks. The training staff makes sure the patient is confident about performing each task before doing home HD. Someone from the clinic will be available to answer phone calls 24 hours a day. Some programs also monitor treatments over the Internet.

The patient returns to the clinic once a month to see the nephrologist, dialysis nurse, and dietitian. A blood sample will be tested to ensure the HD treatments are working and to detect any problems, such as anemia or high potassium levels, that should be treated.

What are the risks of home HD?

Home HD has the same risks for complications that exist with in-center HD, including low blood pressure and infection. The most serious risk is the possibility of an air embolism-a condition in which air is introduced into the blood stream accidentally, preventing the heart from adequately pumping blood. Another serious risk is blood loss if a catheter separates. Home HD patients and their helpers learn to watch for these problems and are trained to act quickly if they arise.

What are the advantages of home HD?

Home HD lets the patient set the schedule. The patient can choose treatment times to fit other activities, such as going to work or caring for a family member.

The patient can dialyze more often at home. People who dialyze at a clinic skip 4 days each week, so wastes and fluid build up in their bodies. Dialyzing at home five to seven times per week means wastes and fluid don't build up as much in the body. Muscle cramps that are common in people using the standard HD may be less common in those who choose home HD because wastes and fluid are cleared more often.

Treatment plans usually follow one of two schedules:

  • Short daily treatments-Some people dialyze at home during the day. Because they do it every day-or at least five or six times a week-they do not have to dialyze as long. They can finish in 2 or 3 hours. And they save even more time because they do not have to travel to and from the clinic. Daily treatments keep blood pressure more level than standard HD. Many people who do daily HD no longer need blood pressure pills.

  • Long nightly treatments-Some people dialyze at night while they sleep. Then they have the whole day free for other activities. The longer time of nightly HD allows for a slower blood flow rate. This gentle treatment is easy on the patient's access and heart. Because the treatments are so long, they remove more phosphorus and other wastes than short treatments can. Many people who do nightly HD no longer need blood pressure pills or phosphate binders. Nightly HD is done from 3 to 6 nights per week.

The schedule can be tailored to fit each person's needs.

Because use of home HD is still increasing, researchers have not been able to do large studies that compare home treatment with standard HD. But dozens of small studies have found better results in patients who do daily or nightly home HD. Reported benefits include

  • better blood pressure control with fewer drugs
  • better control of phosphate levels in the blood
  • less limited diet and fluids than standard HD
  • reversal of some heart damage caused by high blood pressure

People who do home HD say it improves their quality of life. Those who have switched from standard to more frequent home HD say they have more energy, feel less nauseous, and sleep better. Many say they value the control they gain by doing their own treatments.

What are some barriers to home HD?

Although growing, the number of clinics that offer home HD is limited. Some patients may find that the nearest home HD clinic is an hour or two away.

Insurers that pay for HD treatments, including Medicare, have set payment based on the standard schedule of three treatments a week. Clinics may limit daily HD to those who have employer group health plans because payment from Medicare alone would not cover their costs. Medicare rules state, "Claims for hemodialysis furnished more frequently than three times per week must be accompanied with medical documentation explaining the reasons for the additional dialysis sessions" (Medicare Provider Reimbursement Manual, Part 1, Chapter 27 2709). A doctor may need to write a letter saying that daily HD will help the patient have better outcomes. Patients should talk with their insurance provider or clinic social worker about whether payments for daily home HD will be covered. Nightly home HD can be done three times per week and can be paid for by Medicare alone.

Points to Remember

  • New, smaller dialysis machines are making home hemodialysis (HD) more practical.
  • Training for home HD takes 3 to 8 weeks.
  • People doing home HD can choose between shorter daily treatments or longer nightly treatments.
  • People who do home HD say it improves their quality of life.
  • Patients should talk with their insurance provider or clinic social worker about whether payments for daily home HD will be covered.

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