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  Table of Contents  
Year : 2012  |  Volume : 22  |  Issue : 5  |  Page : 323-332

Nocturnal hemodialysis

Department of Renal Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia

Date of Web Publication27-Nov-2012

Correspondence Address:
D Ranganathan
Senior Consultant Nephrologist,Head, Home and Independent Dialysis Services, Royal Brisbane and Women's Hospital Herston, Queensland
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Source of Support: None, Conflict of Interest: None

PMID: 23326041

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Patients receiving conventional hemodialysis have high hospitalisation rates, poor quality of life and survival compared to the general population. Many centres around the world are providing longer hours of hemodialysis - short daily hemodialysis and nocturnal hemodialysis - with a view to improving patient survival and quality of life. Studies have shown that nocturnal haemodiaysis is more effective than conventional hemodialysis in clearing most small, middle and larger molecule toxins and suggest nocturnal dialysis enhances patient survival and quality of life. Concerns include patient acceptance, vascular access related complications and increased cost. The purpose of this review is to examine the advantages and drawbacks of nocturnal dialysis, with a focus on applicability to India where the renal physician has to face cultural and economic barriers, erratic power supply and poor water quality.

Keywords: Australia, India, nocturnal hemodialysis

How to cite this article:
Ranganathan D, John G T. Nocturnal hemodialysis. Indian J Nephrol 2012;22:323-32

How to cite this URL:
Ranganathan D, John G T. Nocturnal hemodialysis. Indian J Nephrol [serial online] 2012 [cited 2019 Jun 24];22:323-32. Available from:

  Introduction Top

End stage renal disease (ESRD) is a major health problem. Renal replacement therapy (RRT) places a considerable burden on health care resources. The survival and quality of life on dialysis have not improved commensurate with the technological advances. The reasons include patients' underlying illness, co-morbidities and the mode of delivery of RRT.

Conventional hemodialysis (CHD), though meeting targets of urea clearance, removes the uremic toxins suboptimally. [1] With the assumption that increasing hours on HD would improve the 'uremic milieu', many centres practise short daily dialysis or longer treatment at night the so-called "nocturnal hemodialysis (NHD)". This article will review whether nocturnal dialysis, either in-centre (INHD) or at patients' home - nocturnal home hemodialysis (NHHD), significantly improves the 'uremic milieu', well-being and survival.

  Conventional HD and its Drawbacks Top

The 'uremic syndrome' is characterised by non-specific symptoms such as increasing tiredness, nausea, loss of appetite and or organ specific illness such as pericarditis or encephalopathy. [2] The pathophysiology of this syndrome is partly due to the retention of nitrogenous waste products from the underlying renal illness; further compounded by co-morbidities. [3],[4] These patients are often unwell, find it difficult to carry out daily activities and will die without RRT.

The principle of dialysis was first described by Graham from Glasgow in 1854. [5] The modern era of dialysis began in 1960 when Wayne Quinton and Belding Scribner showed long term dialysis is possible, using an arterio-venous (AV) shunt. [6] HD has been provided to ESRD patients with the sole view of improving survival since then. In the 1960's HD sessions were long and impractical. In 1972 thrice weekly HD sessions were approved and launched in the United States of America (USA) which has become the bench mark for the subsequent programs. [7]

The National Cooperative Dialysis Study (NCDS), a land mark study [8] supported thrice weekly dialysis, showing time -averaged urea concentration was the most important determinant of patient hospitalisation or withdrawal from the study. There was no correlation of longer time on dialysis with hospitalization rates, withdrawal from the study or death. Subsequently maintenance HD sessions were shortened with high flux, high efficiency haemodialysers to prolong patient survival with reduced costs and improved life-style. [9] Dialysis was delivered to achieve an adequate urea clearance (measured as equivalent Kt/V of 1.2).

The 'Hemodialysis' (HEMO) trial did not find any difference between high Kt/V (single pool Kt/V of 1.71) and standard dose of Kt/V. Also, the use of high flux membrane vs. low flux membrane dialyser did not alter the outcome. [10] However, patients using a high flux membrane could have a survival advantage if they were on dialysis for more than 3.6 years. This study suggested that increasing solute clearance during dialysis may not affect patient outcome. Further, the adequacy of dialysis measured by small solute-urea clearance was indeed less than 15% of clearance that is achieved by normal kidneys. Other factors such as cardiovascular (CV) complications, malnutrition and deranged calcium and phosphate metabolism play a significant role in patient outcomes. [11] It is difficult to maintain euvolemia with CHD resulting in high blood pressure (BP) and related complications including left ventricular hypertrophy. On the contrary the intermittent nature of CHD leads to hemodynamic instability due to excess fluid removal in a short duration. Post hoc analysis of the HEMO study revealed ultrafiltration rate in excess of 13 ml/hour/kg was associated with an increased all cause and CV mortality. [12] The hypotensive episodes during HD induce repeated myocardial stunning resulting in an ischaemic myocardium. [13] It is therefore not surprising that in dialysis patients CV related mortality is over 40%.

  Reasons to Look for Alternative HD Modalities Top

The survival of patients on dialysis has not improved in the past two decades. The expected survival of a 55-year old who is on dialysis is five years and with a functioning allograft, 15 years [14] while an average American would live for another 26 years. It was presumed that increased mortality in dialysis patients was due to inadequate clearances of uremic toxins and poor volume control. Improved patient related outcome is seen in dialysis patients from Tassin, France where patients undergo longer HD sessions, eight hours in a day, thrice weekly. [15] Studies have shown that removal of toxins alone is insufficient for improving well-being of a dialysis patient; the procedure has to be well tolerated with the least hemodynamic disruption. Finally, dialysis must improve the hard end-points namely, quality of life and long-term survival. Australia New Zealand DATA on survival outcome of patients who were on HD from 1997-2006 showed longer hours on dialysis had a clear dose-response relationship with survival. [16] Recent DOPPS data shows longer treatment time on HD is associated with a survival benefit. [17] In view of better survival of patients on longer hours of HD, different modalities have been attempted by the dialysis community including frequent or nocturnal HD. This review focuses on nocturnal dialysis, its advantages and drawbacks.

  Different Modalities of Dialysis Top

CHD is usually performed three times a week. Quotidian dialysis is defined as dialysis that is performed daily or more than thrice weekly. Dialysis modalities can be classified as shown in [Table 1].
Table 1: Classification and characteristics of the various hemodialysis modalities

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The prevalence of nocturnal hemodialysis

The practice of Nocturnal Hemodialysis (NHD) was reported even in the 1960s. [18] Subsequently there was a lack of interest until early 1990s when the Toronto nephrologists reported their success with NHHD. [19] In the late 1990s another group from Montreal reported, their experience with INHD. [20] All over the world, gradually interest has grown and now many HD programs offer NHHD or INHD. In 2004 the 'International Quotidian Dialysis Registry (IQDR) was formed with three Canadian and two US centres to study practices and outcomes associated with more intensive HD prescriptions ( ) and the first report showed that 70 were on NHD and 8 patients on short-daily HD. [21] This registry currently captures data from the dialysis registries of Australia-New Zealand, France, in addition to Canada and dialysis providers of USA. Still, it does not represent a widespread international participation. By March 2010, 2400, 327, 306 and 1175 patients, from Australia, Canada, France and US respectively were receiving short daily or nocturnal HD. The largest number of patients in the registry were from Australia and New Zealand and 68.3% of those patients were on NHHD. Majority (about two thirds) of Canadian patients were on NHD and 93.5% dialysed at home. In the US only 7.2% of patients were on NHHD. [22] There is no registry based information about dialysis of longer duration from Asia.

  Procedure Top

Selection criteria

The patients should be motivated and able to self administer HD. In our centre a multidisciplinary team including a psychologist assesses the patients before accepting them for the nocturnal program. Serious co-morbid conditions such as terminal cardiac failure (CF), diabetes mellitus with intractable coronary artery disease are not contraindications for NHHD or INHD. At our centre 11% of dialysis patients are on home HD and 20% of this group are in the NHHD program. [23]

Training and modality

Patients are given training for four- six weeks in a dialysis centre before they can perform NHD independently at home. Training period is tailored to the individual's learning skills. Patients who are on self-care (day time home HD) can be transferred to NHD program earlier whereas an inexperienced patient will need a longer duration of training. If required, the partner or a family member can be trained to assist with the dialysis procedure but this is not essential. Electrical supply and water connections at patient's home may have to be modified to connect the dialysis equipment. There has to be sufficient space to accommodate the dialysis machine and the water treatment trolley.


Standard dialysis machines and dialysers can be used at home. Higher concentration of calcium is required in the dialysate and many patients on NHD require phosphate supplementation.


Central venous catheters, arterio-venous fistulas (AVF) and grafts have been used. [24] Many centres use single needle devices for NHHD. Both rope / step ladder and buttonhole techniques are used to puncture AVF. There are conflicting reports regarding the use of the buttonhole technique. Van Eps et al, [25] report increased incidence of infectious complications with buttonhole technique while Quinitaliani [26] et al, report no significant increase in adverse effects. In our centre, we predominantly use button-hole technique without major complications. Each centre has to choose the technique best suited to their patients.

Safety alarms

A blood leak detector alarm [Figure 1] is taped around the AVF needles to detect blood leak. Moisture sensing device is placed under the machine, on the floor to detect blood or dialysate leaks. Commercially available clip -lock 'connector boxes' over central venous catheters can be used to prevent accidental disconnection and air embolism. 'Back slabs' can be used to protect and stabilise the AVF needles. Currently we do not use any of these devices excepting blood leak detector alarm. We generally avoid using central venous catheter for NHHD patients.
Figure 1: 'Blood leak detector': 'Enuresis pad' between cannulas to detect blood leak. DRI-Sleeper(TM) [flexible], Alpha Consultants, Nelson, New Zealand (

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Some centres monitor their patients from remote locations 'live' either by internet or via telephone while their patients perform NHHD. [27] Our patients use a bedside telephone and have a nurse on call for troubleshooting. Generally patients are advised to terminate HD if they encountered problems at night and to contact the centre the following morning.

Water treatment unit

The water treatment unit is dependant on the purity of the source water. At regular intervals water has to be tested to maintain the standards of quality as advocated by the Association for the Advancement of Medical Instrumentation. [28] The unit that we use in our NHD program contains a five micron particle filter, two carbon filters, one micron filter, reverse osmosis (RO) system and a Diasafe® filter (Fresenius Medical Care), all connected in series. Water is filtered first by the 5 micron filters and then passed through carbon filters, one micron filter, RO system [Figure 2] and finally through the Diasafe® connected at the back of the HD machine. The five micron filter eliminates dirt from the water before going through the carbon filters while the one micron filter removes finer material and bacteria before the water enters the RO unit. Water filters have to be changed monthly. The aim is to keep the slit density index (SDI) to less than five as most RO membrane manufactures recommend that feed water SDI should not exceed a value of 5.0 ( ). Carbon filter gets rid of excess chloramines, some pesticides and plant particles but it needs to be backwashed monthly and changed annually. The RO system removes pyrogens, bacteria, excess salts such as sodium and aluminium and Diasafe, endotoxins.
Figure 2: Water treatment equipment

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Water testing is done every three months. Chlorine and chloramine are tested before and after the carbon filter; bacterial counts at the RO unit and at the venous port of the dialysis machine; endotoxin assay is performed from the water at the venous port while the tests for heavy metals and trace elements is done from the inlet supply and the post RO water source.

  Advantages of nocturnal hemodialysis Top

Small solute clearance

Small solute clearance in CHD is traditionally measured by a urea kinetic modelling-'Kt/V'. This modelling measures the urea clearance with an assumption that urea is generated at a constant rate. In nocturnal HD the urea generation rate at night time is shown to be lower than the day time. [29] Further the urea falls significantly by about 75% in first two hours of HD and then on falls slowly through the rest of the treatment. This implies that although NHD sessions are longer, they may not have an advantage in urea clearance compared to CHD. Therefore the method to measure urea clearance is not optimised and validated in nocturnal HD. However many studies have shown that NHD significantly improves small solute clearance (measured as percentage reduction in urea (PRU) or equilibrated Kt/V (eKt/V)). A single centre study from Toronto has shown that PRU increased from 74 to 89% when they converted 39 patients from conventional HD to INHD (P < 0.001). [30] A multicentre study has compared single session eKt/V of 655 INHD patients to matched 15,334 conventional HD patients. The single session eKt/V of conventional HD patients was 1.46 ± 0.32 whereas that of nocturnal HD group was 2.21 ± 0.56. [31] Lindsay et al. from Ontario, Canada has demonstrated that a group of NHHD patients who received nocturnal HD -six sessions in a week, had weekly e Kt/V 8.11 ± 0.46 compared to 4.26 ± 0.17 in the conventional group (P < 0.001). [32] These studies highlight that nocturnal HD, either INHD or NHHD improves small solute clearance. However, the ideal measurement of small solute clearance in NHD is yet to be established.

Middle and large molecule clearance

The diffusive clearance of middle and large molecules depends on the duration of dialysis as there is a gradient maintained between the vascular and dialysate compartments for these substances. It is therefore expected that NHHD and INHD are effective in removing larger molecules in addition to a better clearance of small molecules. Studies have suggested that a longer duration of HD results in a greater clearance of β2 microglobulin. [33] Advanced Glycated End products and homocysteine levels decrease with nocturnal dialysis compared to conventional dialysis. [34] The effect of INHD or NHHD on the removal of highly protein bound substances such as hippuric acid, indoxyl sulphate, indole 3 acetic acid, methyl guanidine and guanadino-succinic acid, 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid has not been examined in depth.

Middle molecules can be better removed by using a convective technique using high flux membranes without extending the duration on dialysis. Hemodiafiltration (HDF) combines high flux HD with ultrafiltration of large amounts of plasma water, needing near-equivalent volumes replaced with an appropriately constituted fluid. In 'Online HDF' (OL-HDF), the substitution fluid is generated online that is safe, free of pyrogens and toxins. This therapy is well tolerated but there is no survival benefit. [35] A recent study has shown OL-HDF on alternate nights is better compared with 4-5 hr thrice weekly OL-HDF in improving the dialysis dose, BP, nutrition and occupational rehabilitation. [36]

Calcium, phosphorous and PTH

Studies have consistently shown improved phosphate control in patients on IHND or NHHD. A randomised controlled trial has shown NHHD group had significantly more decrease of phosphate compared to CHD patients, despite the marked reduction in the use of phosphate binders in NHD group. [37] Further, many patients require the addition of phosphate into the dialysate concentrate commonly as sodium phosphate. [38] Low bone turn over is demonstrated in bone biopsies of NHD patients. Dialysate calcium has to be kept at a higher level to minimise the decline of bone mineral density. [39] High dialysate calcium is prescribed to reduce PTH levels in NHD although this is not a proven strategy. [37],[39]

Haematological effects

NHHD patients self-administer erythropoietin and intravenous iron during dialysis. The majority report either an increase in haemoglobin or a decreased requirement of erythropoietin. [40] There is an increase in the number of early-outgrowth endothelial progenitor like hematopoietic cells in nocturnal dialysis. [41] In contrast, a recent report has failed to show improvement of haemoglobin in NHD patients. [42] The inconsistent results with treatment of anaemia may be due to diverse populations and varied targets for iron replenishment.

Cardiovascular effects

Many studies have evaluated various CV changes in patients undergoing NHD. This includes BP and volume control, and reduction in left ventricular mass (LVM). The studies with patients undergoing NHD have shown that there is good BP control with minimal requirement of antihypertensive drugs. [42],[43] The BP control in NHD patients depends on other factors in addition to volume control. Nesrallah et al, showed improved control of BP in their groups of 11 patients on SDHD and 12 patients on NHD but the reduction in extracellular fluid volume was mainly seen in SDHD group only. [44] In NHD patients reduced levels of catecholamines and endothelium dependant peripheral vasodilation play a role in BP control. [45],[46] In NHD patients studies have shown not only improved BP control, but also better LV function. Culleton from Alberta was the first to conduct a randomised trial to study the effects of NHD on LVM. This randomised controlled trial comparing 26 NHHD patients to 25 CHD patients found regression of LVH. [42] He demonstrated a reduction in LVM in NHD group when compared to CHD group (reduction in LVM 13.8 ± 23.8 g vs. increase in LVM in CHD group 1.5 ± 24.0g; P 0.004). The limitations of this trial were a small sample size and a short follow up period of six months only. In patients on NHD who had cardiac failure improved LV ejection fraction was demonstrated. [47] Frequent Hemodialysis Network (FHN) trial on daily in-centre HD has shown significant reduction in LVM as measured by magnetic resonance imaging. [48] In this study 125 and 120 patients were randomised to undergo intermittent HD 6 times per week and CHD (three times per week) respectively. At the same time the 'Frequent Hemodialysis Nocturnal Network (FHNN) trial' did not demonstrate significant reduction in LVM in NHD patients having randomised 45 patients to the nocturnal arm and 42 to the conventional arm. [49] The reasons for different outcomes in these studies are multifactorial as discussed below.


NHD improves appetite and eliminates the need of dietary restrictions. NHD increases intake of protein, as measured by normalised protein catabolic rate and dietary intake. [50] Total body nitrogen improves in NHD patients even though there is loss of amino acids into the dialysate. [51] It also improves intake of other nutrients such as lipids, phosphorous with preservation of calcium, phosphorous and potassium levels in blood. [52] Nevertheless, despite improved nutrition, overall survival is yet to be demonstrated.

Sleep disturbances

Sleep disturbance in ESRD patients is considered as one of the indicators of suboptimal dialysis. [53] Sleep disorders such as sleep apnoea, restless legs while asleep and daytime sleepiness predict mortality in HD patients. [54] It has been shown that NHD improves sleep apnoea though it may not improve day time sleepiness or periodic limb movements. It is hypothesised that the cross sectional luminal area of pharynx increases when patients are shifted from CHD to NHD, reducing sleep apnoea. [55] Sleep disorders in NHD patients need further study.

Endocrine and reproductive functions

Fertility is adversely affected in patients with ESRD and does not improve with CHD. Nocturnal HD improves fertility and reduces foetal and maternal complications. [56] NHHD reduces prolactin levels and may help re-establish regular menstrual periods in women and improves testosterone levels in males. [57]

Quality of life

The results on assessment of Quality of life (QOL) measurements in NHD are conflicting. Many studies have demonstrated improved QOL measures. [30],[32],[58] The Toronto group demonstrated that IHND patients had improved overall QOL score. [30] Fresenius group showed no improvement in mental component of SF-36 score but showed better physical component of SF-36 score in INHD patients. [32] QOL score of patients on NHHD also observed to be better than the patients receiving CHD. [58] A recent study did not show improved QOL score in NHD patients. [59] However IHND and NHHD are better than CHD in improving overall QOL in particular with the poorly performing CHD patients. [4]


Hospitalisation rates are lower in patients on NHD. A case-control study from North America compared 655 patients who were on thrice-weekly INHD with 15334 CHD patients from the same geographic area. IHND patients were reported to have fewer annual hospitalisation rates (48 vs. 59%). They had fewer normalized hospitalization events at 1.26 vs. 1.74 hospitalization events per patient-year, and a lower normalized rate of 9.6 vs. 13.5 hospital days per patient-year (P < 0.0001). [60] Studies in NHHD patients also have demonstrated decreased hospitalisation rates. [61]

  Survival Top

Survival benefit is considered as the most important outcome of dialysis therapy. A number of reports on nocturnal dialysis have addressed this issue. A study from Canada, 'CAN-Sleep' involving 247 patients did not find a significant relationship between frequency of dialysis and mortality. [61] A group from USA analysed the data from United States Renal Data System (USRDS) in both NHD and CHD patients. They found the mortality rate in 94 NHD patients was a third of that in 940 CHD patients. (P = 0.0001). [62] Another group of investigators compared survival of 171 NHD patients who were on NHD from 1994 to 2006, to 1062 living and 1062 deceased donor transplants. This data derived from USRDS revealed that the survival of NHD patients is comparable to deceased donor transplant (hazard ratio 0.87, 95% CI 0.50-1.51, P = 0.61) though not as good as living donor transplants (hazard ratio 0.51, 95% CI 0.28-0.91, P 0.02). [63] Three randomised controlled trials, Alberta Study, FHN and FHNN trial were designed to determine the beneficial changes of LVM associated with longer hours on dialysis. [42],[48],[49] The FHN trial demonstrated that frequent daily dialysis improved co-primary outcomes (hazard ratio for death or increase in LVM, 0.61; 95% confidence interval (CI, 0.46 to 0.82). [48] The FHNN trial did not show any survival advantage or decrease in LVM with NHD compared to CHD. [49] The nocturnal group received 1.82-fold higher mean weekly standard Kt/V urea compared to conventional group. Further, this study failed to show improvement in many of the secondary outcomes including markers of nutrition, hospitalisation rate, haemoglobin, physical health composite score and self-reported depression. The study showed only improvement in control of BP and phosphate. There are certain issues involved in the design and methodology of FHNN study. [64],[65] This study has detected (mean) 10.9g (CI -23.7 + 1.8) reduction in LVM. The reduction in LVM in this study is similar to the observations found in the study done by Alberta study though it was not statistically significant. Further there were baseline differences between these two studies: patients were younger, longer on dialysis and LV mass of conventional group is 137.1 ± 45.7g in FHNN study compared to relatively older and baseline LV mass of 181.5 ± 92.3g in the CHD arm of Alberta study. These findings suggest the patients of Alberta study have chronic disease of the heart and thereby benefit shown with NHD. Further FHNN study is underpowered as they could randomise only 87 patients though the target was 250 patients. Secondly, the time on dialysis is not significantly different between the patients in the two arms. Patients in the CHD arm received an average of 256 minutes of HD per session, about 45 minutes more than the US HD patient whereas the patients in NHD group received about less than 10 hrs of HD per week than the standard NHD patients. In the nocturnal group only about three fourths of the patients could complete the prescribed dialysis time. The next question is why FHNN did not demonstrate the improvement in LVM or survival benefit when daily FHN study showed benefits in both co-primary outcomes. The daily FHN trial had more power to detect the difference as the number of participants recruited into this study was three-fold that of FHNN study. The FHN trial though did not show a significant reduction in LVM but there was still a possibility of a large treatment effect. This is shown by a 19 gm reduction in LVM with a 95% confidence interval. One cannot therefore conclude that frequent nocturnal HD is inferior to frequent daily in-centre HD. [66] It is important to point out that no study has assessed the impact of NHD on CV mortality.

  Cost Effectiveness Top

Cost estimates in dialysis involve actual (dialysis equipment, dialysate, dialyser, water, water treatment unit, electricity, medication) and hidden expenses. Hidden expenses include wages of the multidisciplinary team, cost of training and follow up, hospitalisation, establishment and maintenance of the dialysis centre. The cost difference depends on the site of dialysis - home vs. in-centre and or nocturnal vs. conventional. If a patient is undergoing HD at home and in particular longer hours on dialysis, the cost on infrastructure and labour may be avoided but the cost may increase due to training, requirement of one HD machine per patient and extra- supplies. However studies from Australia and Canada have shown the cost involved with IHND or NHHD is less than CHD. [67],[68]

  Barriers Top

The main roadblocks to NNHD are either with dialysis providers' attitude toward funding or patients' perceptions regarding the difficulties of the procedure. Service providers may be reluctant to pay for escalating direct costs of longer and daily HD. Further, the lack of training and experience with instructing patients to perform HD at home could impede the program. Patients are hesitant to adopt the nocturnal program due to lack of motivation, missing the comfort of in-centre dialysis, fear of self-cannulation, poor confidence and family support, inadequate home facilities or water supply, increasing electricity and water bill and fear of adverse consequences. [69] The advent of patient friendly HD machines would attract both the patients and the training staff to expand this program.

  Future Top

The main drawbacks of NHD are the barriers listed above and also a trend towards increasing vascular access related problems. [21],[49],[69] However nearly 44% of the vascular access related complications observed in FHNN study occurred in patients who used CV catheters, which are generally not encouraged by NHD centres. [49] The FHNN study showed improved BP and phosphate control in the nocturnal arm though it did not show survival benefit due to multiple factors as discussed before. In addition the Alberta study and many observational studies have shown improvement in many clinical parameters with INHD or NHHD as discussed earlier. A Clinical Trial of IntensiVE (ACTIVE) study, currently in progress may shed more light on QOL with longer hours on HD. Randomised controlled studies have to be conducted comparing OL-HDF and CHD and NHD. It would be difficult to perform OL-HDF at home due to complex nature of the HDF machine. In future, NHD machines have to be compact, portable and needing fewer consumables, allowing patients to travel for work or leisure with their machines. In the meantime one should continue to support the NHD program but with careful selection of motivated patients.

  Our Experience Top

Our unit advocates the policy of 'First Home Therapy- either PD or home hemodialysis (HHD)'. The patients opting to HHD are identified and educated on HHD even before they enter the dialysis program. All our patients who enter NHHD were initially trained on HHD for four to six weeks and perform HHD for few months. Then patients who opt to undergo NHHD perform three sessions of nocturnal dialysis using Fresenius 4008 B machines in the training centre programmed with target 'dialysis parameters' as shown in [Table 1]. Our patients use the dialysate as shown in [Table 2] and for an eight hours session of NHHD, a five litre of Part A concentrate and 950g of Bibag (Part B -Bicarbonate concentrate) are required. The dialysate flow is reduced to 300 ml/minute and therefore five litres of Part A concentrate is sufficient to complete eight hours of HD. In an alternate day protocol of 8 hours NHHD, the dialysate is run at 500ml/minute. The patient has to change the container or decant 2 × 5 litres of concentrate into a 10 litre jerry can, late into the night.
Table 2: Comparison of 'dialysate' used in CHD vs. NHD at Royal Brisbane and Women's Hospital[22]

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Of the 17 patients on NHHD, six patients subsequently underwent deceased donor transplantation. Currently six patients continue on NHHD and one of them has been on NHHD for the past 75 months. Two patients who trained in our program then transferred to a neighbouring district. In our 400 patient months of experience on NHHD, we came across only one blood leak from accidental disconnection of AV fistula needle. Two patients had infection related to vascular access and one improved with antibiotics. The second patient had infective endocarditis following access infection, had to undergo mitral valve replacement and is on in-centre HD. One patient had a thrombosed fistula due to high haemoglobin, and was transferred to PD. Another patient died of bronchiectasis.

  Applicability to India Top

Is it possible to expand the NHD program for dialysis patients in India? In 1963 one of the patients trained by Dr. Scribner returned home to Chennai and became the first to be on home HD in the country. [70] However home HD programs are not popular in India and currently few centres offer home and nocturnal dialysis. ( 'nocturnal-dialysis'working-patients-160921.html ). There is no registry or published data on NHD from India. A program aiming to start NHD in India has to address issues such as cultural barriers, water quality and erratic electrical power supply. One of the major problems is the quality of feed water, in particular during monsoon. Water filters may have to be changed fortnightly or even weekly instead of monthly. Continuous power supply with a stable voltage in sine wave is essential. An online UPS with sufficient capacity to run the dialysis machine with a backup for at least 30 mins is recommended. The use of surge protectors is necessary to protect electronics of the dialysis machine. ( http:/: ). A generator with a capacity of two KW/hour is recommended as the electrical requirement for an hour of hemodialysis is 1.5 KW. Dialysis care provider has to brief the patient on HHD regarding the electrical safety requirements and the risks of use of other equipment in the area. If these concerns are attended to, NHD can be offered to selected patients with a favourable cost-benefit ratio. [Table 3] provides a suggested roadmap for starting NHD services.
Table 3: Road Map to NHD

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  Acknowledgment Top

Jock Howes, Anne Salisbury, Sally Goodwin, Rebecca Russo and all nursing staff, Home HD Program, Department of Renal Medicine, Royal Brisbane and Women's Hospital.

  References Top

1.Basile C, Libutti P, Di Turo AL, Casino FG, Vernaglione L, Tundo S, et al. Removal of uraemic retention solutes in standard bicarbonate hemodialysis and long-hour slow-flow bicarbonate hemodialysis. Nephrol Dial Transplant 2011;26:1296-303.  Back to cited text no. 1
2.Almeras C, Argilés A. The general picture of Uremia. Semin Dial 2009;22:329-33.  Back to cited text no. 2
3.Mcfarlane PA. More of the same: Improving outcomes through intensive hemodialysis. Semin Dial 2009;22:598-602.  Back to cited text no. 3
4.Mcfarlane PA. Nocturnal hemodialysis: Effects on solute clearance, quality of life, and patient survival. Curr Opin Nephrol Hypertens 2011;20:182-8.  Back to cited text no. 4
5.Graham T. The Bakerian lecture: On osmotic force. Philos Trans R Soc Lond A 1854;144:177-228.  Back to cited text no. 5
6.Quinton W, Dillard D, Scribner BH. Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Intern Organs 1960;6:104-13.  Back to cited text no. 6
7.Available from: Basics_dialysis.pdf.accessed 20 March 2012.  Back to cited text no. 7
8.Lowrie EG, Laird NM, Parker TF, Sargent JA. Effect of the hemodialysis prescription of patient morbidity: Report from national cooperative dialysis study. N Engl J Med 1981;305:1176-81.  Back to cited text no. 8
9.Tokars JI, Alter MJ, Miller E, Moyer LA, Favero MS. National surveillance of dialysis associated disease in the United States- 1994. ASAIO J 1997;43:108-19.  Back to cited text no. 9
10.Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002;347:2010-9.  Back to cited text no. 10
11.Goodkin DA, Bragg-Gresham JL, Koenig KG, Wolfe RA, Akiba T, Andreucci VE, et al. Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan and the United States: The Dialysis, Outcomes and Practice Patterns study (DOPPS). J Am Soc Nephrol 2003;14:3270-7.  Back to cited text no. 11
12.Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney Int 2011;79:250-7.  Back to cited text no. 12
13.McIntyre CW. Hemodialysis-induced myocardial stunning in chronic kidney disease - a new aspect of cardiovascular disease. Blood Purif 2010;29:105-10.  Back to cited text no. 13
14.US Renal Data Systems. USRDS 2009 Annual Data Report. Bethesda MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2009.  Back to cited text no. 14
15.Laurent G, Charra B. The results of an 8 hr thrice weekly hemodialysis schedule. Nephrol Dial Transplant 1998;13 Suppl 6:125-31.  Back to cited text no. 15
16.Kerr PG, Polkinghorne KR, Mcdonald SP. Home hemodialysis in Australia: Current prospective. Hemodial Int 2008;12 Suppl 1:S6-10.  Back to cited text no. 16
17.Eschbacj JW Jr, Wilson WE Jr, Peoples RW, Wakefield AW, Babb AL, Scribner BH. Unattended overnight home hemodialysis. Trans Am Soc Artif Intern Organs 1966;12:346-56.  Back to cited text no. 17
18.Tentori F, Jinyao Zhang J, Yun Li Y, Angelo Karaboyas A, Kerr P, Saran R, et al. Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-centre three times per week hemodialysis: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant Mar 19, 2012 [Epub ahead of print]doi: 10.1093/ndt/gfs021.  Back to cited text no. 18
19.Pierratos A. Nocturnal home hemodialysis: An update on a five year experience. Nephrol Dial Transplant 1999;14:2835-40.  Back to cited text no. 19
20.Déziel C. Rediscovering long duration hemodialysis. Nephrol News Issues 1997;11:41-2.  Back to cited text no. 20
21.Nesrallah G, Garg AX, Moist LM, Suri RS, Lindsay RM. The international quotidian dialysis registry: Annual report 2005. Hemodial Int 2005;9:203-9.  Back to cited text no. 21
22.Lindsay RM, Suri RS, Moist LM, Garg AX, Cuerden M, Langford S, et al. International quotidian dialysis registry: Annual report 2010. Hemodial Int 2011;15:15-22.  Back to cited text no. 22
23.Manickam V, Goodwin S, Salisbury A, Ranganathan D. Nocturnal home hemodialysis program: The Royal Brisbane Experience. Nephrology 2006;11.s2:A33   Back to cited text no. 23
24.Pierratos, Goluboff D, Ouwendyk M. Vascular access for nocturnal hemodialysis (abstract). J Am Soc Nephrol 1999;10:215 A.  Back to cited text no. 24
25.Van Eps CL, Jones M, Ng T, Johnson DW, Campbell SB, Isbel NM, et al. The impact of extended-hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access. Hemodial Int 2010;14:451-63.  Back to cited text no. 25
26.Quintaliani G, Buoncristiani U, Fagugli R, Kuluiranu H, Ciao G, Rondini L, et al. Survival of vascular access during daily and three times a week hemodialysis. Clin Nephrol 2000;53:372-7.  Back to cited text no. 26
27.Hoy CD. Remote monitoring of daily nocturnal hemodialysis 2003. Hemodial Int 2004;8:144-50.  Back to cited text no. 27
28.Standard of Care for Maintenance Hemodialysis - available from 31-39. accessed 20 March 2012.  Back to cited text no. 28
29.Daugirdas JT, Depner TA, Greene T, Levin NW, Chertow GM, Rocco MV, et al. Frequent Hemodialysis Network (FHN) Trial Group. Effects of reduced intradialytic urea generation rate and residual renal clearance on modeled urea distribution volume and Kt/V in conventional, daily, and nocturnal dialysis. Semin Dial 2010;23:19-24.  Back to cited text no. 29
30.Bugeja A, Dacouris N, Thomas A, Marticorena R, McFarlane P, Donnelly S, et al. In-center nocturnal hemodialysis: Another option in the management of chronic kidney disease. Clin J Am Soc Nephrol 2009;4:778-83.  Back to cited text no. 30
31.Lacson E Jr, Wang W, Lester K, Ofsthun N, Lazarus JM, Hakim RM. Outcomes associated with in-center nocturnal hemodialysis from a large multicenter program Clin J Am Soc Nephrol 2010;5:220-6.  Back to cited text no. 31
32.Suri R, Depner TA, Blake PG, Heidenheim AP, Lindsay RM. Adequacy of quotidian hemodialysis. Am J Kidney Dis 2003;42 (1 Suppl):42-8.  Back to cited text no. 32
33.Raj DS, Ouwendyk M, Francoeur R, Pierratos A. Beta (2)-microglobulin kinetics in nocturnal hemodialysis. Nephrol Dial Transplant 2000;15:58-64.  Back to cited text no. 33
34.Friedman AN, Bostom AG, Levey AS, Rosenberg IH, Selhub J, Pierratos A. Plasma total homocysteine levels among patients undergoing nocturnal versus standard hemodiaysis. J Am Soc Nephrol 2002;13:265-8.  Back to cited text no. 34
35.Grooteman MP, van den Dorpel MA, Bots ML, Lars Penne E, van der Weerd NC, Mazairac AH, et al. For the CONTRAST Investigators. Effect of online hemodiafiltration on all-cause mortality and cardiovascular outcomes. J Am Soc Nephrol 2012;23:1087-96.  Back to cited text no. 35
36.Maduell F, Arias M, Durán CE, Vera M, Fontseré N, Azqueta M, et al. Nocturnal, every-other-day, online haemodiafiltration: An effective therapeutic alternative. Nephrol Dial Transplant 2012;27:1619-3135.  Back to cited text no. 36
37.Walsh M, Manns BJ, Klarenbach S, Tonelli M, Hemmelgarn B, Culleton B. The effects of nocturnal compared with conventional hemodialysis on mineral metabolism: A randomized-controlled trial. Hemodial Int 2010;14:174-81.  Back to cited text no. 37
38.Su WS, Lekas P, Carlisle EJ, Cowin R, Bellamy J, Margetts PJ, et al. Management of hypophosphatemia in nocturnal hemodialysis with phosphate-containing enema: A technical study. Hemodial Int 2011;15:219-25.  Back to cited text no. 38
39.Al-Hejaili F, Kortas C, Leitch R, Heidenheim AP, Clement L, Nesrallah G, et al. Nocturnal but not short hours quotidian hemodialysis requires an elevated dialysate calcium concentration. J Am Soc Nephrol 2003;14:2322-8.  Back to cited text no. 39
40.Schwartz DI, Pierratos A, Richardson RM, Fenton SS, Chan CT, Schwartz DI, et al. Impact of nocturnal home hemodialysis on anemia management in patients with end-stage renal disease. Clin Nephrol 2005;63:202-8.  Back to cited text no. 40
41.Chan CT, Liu PP, Arab S, Jamal N, Messner HA. Nocturnal hemodialysis improves erythropoietin responsiveness and growth of hematopoietic stem cells. J Am Soc Nephrol 2009;20:665-71.  Back to cited text no. 41
42.Culleton BF, Walsh M, Klarenbach SW, Mortis G, Scott-Douglas N, Quinn RR, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: A randomized controlled trial. JAMA 2007;298:1291-9.  Back to cited text no. 42
43.Walsh M, Culleton B, Tonelli M, Manns B. A systematic review of the effect of nocturnal hemodialysis on blood pressure, left ventricular hypertrophy, anemia, mineral metabolism, and health-related quality of life. Kidney Int 2005;67:1500-8.  Back to cited text no. 43
44.Nesrallah G, Suri R, Moist L, Kortas C, Lindsay RM. Volume control and blood pressure management in patients undergoing quotidian hemodialysis. Am J Kidney Dis 2003;42 (1 Suppl):13-7.  Back to cited text no. 44
45.Chan CT, Harvey PJ, Picton P, Pierratos A, Miller JA, Floras JS. Short-term blood pressure, noradrenergic, and vascular effects of nocturnal home hemodialysis. Hypertension 2003;42:925-31.  Back to cited text no. 45
46.Chan CT, Jain V, Picton P, Pierratos A, Floras JS, Chan CT, et al. Nocturnal hemodialysis increases arterial baroreflex sensitivity and compliance and normalizes blood pressure of hypertensive patients with end-stage renal disease. Kidney Int 2005;68:338-44.  Back to cited text no. 46
47.Chan C, Floras JS, Miller JA, Pierratos A. Improvement in ejection fraction by nocturnal hemodialysis in end-stage renal failure patients with coexisting heart failure. Nephrol Dial Transplant 2002;17:1518-21.  Back to cited text no. 47
48.FHN Trial Group, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, Gassman JJ, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med 2010;363:2287-300.  Back to cited text no. 48
49.Rocco MV, Lockridge RS Jr, Beck GJ, Eggers PW, Gassman JJ, Greene T, et al. Frequent Hemodialysis Network (FHN) Trial Group. The effects of frequent nocturnal home hemodialysis: The Frequent Hemodialysis Network Nocturnal Trial. Kidney Int 2011;80:1080-91.  Back to cited text no. 49
50.Ipema KJ, van der Schans CP, Vonk N, de Vries JM, Westerhuis R, Duym E, et al. A difference between day and night: Protein intake improves after the transition from conventional to frequent nocturnal home hemodialysis. J Ren Nutr 2012;22:365-72.  Back to cited text no. 50
51.Pierratos A, Ouwendyk M, Rassi M. Total body nitrogen increases on nocturnal hemodialysis. J Am Soc Nephrol 1999;10:299A.  Back to cited text no. 51
52.Schorr M, Manns BJ, Culleton B, Walsh M, Klarenbach S, Tonelli M, et al. Alberta Kidney Disease Network. The effect of nocturnal and conventional hemodialysis on markers of nutritional status: Results from a randomized trial. J Ren Nutr 2011;21:271-6.  Back to cited text no. 52
53.Perl J, Unruh ML, Chan CT. Sleep disorders in end-stage renal disease: ′Markers of inadequate dialysis? Kidney Int 2006;70:1687-93.  Back to cited text no. 53
54.Jung HH, Lee JH, Baek HJ, Kim SJ, Lee JJ. Nocturnal hypoxemia and periodic limb movement predict mortality in patients on maintenance hemodialysis. Clin J Am Soc Nephrol 2010;5:1607-13.  Back to cited text no. 54
55.Beecroft JM, Hoffstein V, Pierratos A, Chan CT, Mcfarlane P, Hanly PJ. Nocturnal hemodialysis increases pharyngeal size in patients with sleep apnoea and end-stage renal disease. Nephrol Dial Transplant 2008;23:673-9.  Back to cited text no. 55
56.Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful pregnancies on nocturnal home hemodialysis. Clin J Am Soc Nephrol 2008;3:392-6.  Back to cited text no. 56
57.Van Eps C, Hawley C, Jeffries J, Johnson DW, Campbell S, Isbel N, et al. Changes in serum prolactin, sex hormones and thyroid function with alternate nightly nocturnal home hemodialysis. Nephrology (Carlton) 2012;17:42-7.  Back to cited text no. 57
58.McFarlane PA, Bayoumi AM, Pierratos A, Redelmeier DA. The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis. Kidney Int 2003;64:1004-11.  Back to cited text no. 58
59.Manns BJ, Walsh MW, Culleton BF, Hemmelgarn B, Tonelli M, Schorr M, et al. Alberta Kidney Disease Network. Nocturnal Hemodialysis does not improve overall measures of quality of life compared to conventional hemodialysis. Kidney Int 2009;75:542-9.  Back to cited text no. 59
60.Bergman A, Fenton SS, Richardson RM, Chan CT. Reduction in cardiovascular related hospitalization with nocturnal home hemodialysis. Clin Nephrol 2008;69:33-9.  Back to cited text no. 60
61.Pauly RP, Maximova K, Coppens J, Asad RA, Pierratos A, Komenda P, et al. CAN-SLEEP Collaborative Group. Patient and technique survival among a Canadian multicenter nocturnal home hemodialysis cohort. Clin J Am Soc Nephrol 2010;5:1815-20.  Back to cited text no. 61
62.Johansen KL, Zhang R, Huang Y, Chen SC, Blagg CR, Goldfarb-Rumyantzev AS, et al. Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: A USRDS study. Kidney Int 2009;76:984-90.  Back to cited text no. 62
63.Pauly RP, Gill JS, Rose CL, Asas RA, Chery A, Pierratos A, et al. Survival among nocturnal home hemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant 2009;24:2915-9.  Back to cited text no. 63
64.Culleton BF, Asola MR, Culleton B, Asola MR. The impact of short daily and nocturnal hemodialysis on quality of life, cardiovascular risk and survival. J Nephrol 2011;24:405-15.  Back to cited text no. 64
65.Kerr PG. Dialysis: Nocturnal hemodialysis--should we still provide this therapy? Nat Rev Nephrol 2011;7:611-2.  Back to cited text no. 65
66.Stokes JB. Nocturnal hemodialysis: Analysis following the frequent hemodialysis network trial. Semin Dial 2011;24:614-20.  Back to cited text no. 66
67.Agar JW, Knight RJ, Simmonds RE, Boddington JM, Waldron CM, Somerville CA. Nocturnal hemodialysis: An Australian cost comparison with conventional satellite hemodialysis. Nephrology (Carlton) 2005;10:557-70.  Back to cited text no. 67
68.McFarlane PA, Pierratos A, Redelmeir DA. Cost savings of home nocturnal versus conventional in-center hemodialysis. Kidney Int 2002;62:2216-22.  Back to cited text no. 68
69.Pipkin M, Eggers PW, Larive B, Rocco MV, Stokes JB, Suri RS, et al.; Frequent Hemodialysis Network Trial Group. Recruitment and training for home hemodialysis: Experience and lessons from the nocturnal dialysis trial. Clin J Am Soc Nephrol 2010;5:1614-20.  Back to cited text no. 69
70.Available from: 20 March 2012  Back to cited text no. 70


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