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|Year : 2020 | Volume
| Issue : 7 | Page : 87-88
|Date of Web Publication||15-Jul-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Home hemodialysis. Indian J Nephrol 2020;30, Suppl S1:87-8
| Introduction|| |
The first description of the novel concept of performing HD at home was by Nosé in Japan over half a century ago. Though increasing in popularity in developing countries, this therapy is yet to gain a foothold in India.
| Identification of a Patient for Home Hemodialysis|| |
We suggest that wherever possible, introduction of the concept of home HD must be done early, i.e., in the pre-ESRD stage itself along with discussion regarding all RRT modalities and timely vascular access planning.
We suggest that each individual patient be evaluated for the essential attributes of home HD.
The essential attributes of the ideal home HD patient are listed below:
- Motivation and commitment to home based therapy with willingness to learn
- Clinically stability, i.e., no major active comorbidities or serious complications
- Life expectancy >2 years (This is a soft point and the therapy can definitely be offered for those who are terminal or where ambulation is difficult)
- Literate and intelligent – Able to learn quickly and diligently follow the protocol
- Choice of modality geared to suit lifestyle
- Good dexterity and sight
- Literate with good self-management skills
- Physically and cognitively adept able to dialyze independently (or supported by caregiver)
- Established and reliable vascular access
- Suitable storage and space
- Adequate and stable water and electricity supply
- Telephone access
- Approval of landlord for plumbing modifications, where relevant
- Supportive caregiver is nearly always required
- Access to respite care, if needed
The following categories of patients may be ideally suited for home HD:
- Patients who wish to continue to work or continue their education
- Patients who have failed peritoneal dialysis and wish to continue home based RRT
- Women who are pregnant or planning to conceive
- Patients with the following medical conditions: Severe sleep apnea, persistent hyperphosphatemia, right heart failure, uncontrolled ascites, refractory volume overload, difficult-to-control HTN, symptomatic hypotension, cramps, or nausea on conventional HD, persistence of uremic symptoms on conventional HD or requiring excessive recovery time after conventional HD
Similarly, there are important contraindications to doing HD at home. A few examples are listed below:
- Unstable medical conditions (e.g., uncontrolled arrhythmia, seizure disorder)
- Lack of suitable vascular access
- Unstable behavioral problems (e.g., uncontrolled psychosis or anxiety, ongoing injection drug use and alcohol abuse)
- Contraindication to anticoagulant use during dialysis
- Conditions that may cause abrupt loss of consciousness (e.g., severe and unstable intradialytic hypotension)
We recommend that the patients must be explained the pros and cons of doing home HD and they must be helped make an informed decision. The patient or family member may either learn to do the dialysis by himself or may employ the assistance of a dialysis nurse or therapist to do the same if they are unable/unwilling to do self-care HD.
| Key Members of the Home Hemodialysis Team|| |
We suggest that the key members of the home HD team are the nephrologist, the home HD trainer (nurse/therapist), nutritionist, social worker (cum psychologist), and “home care partner” (family member of the patient).
| Physical Infrastructure of Training Center|| |
While there are different models of training facilities, the easiest to organize is within the hospital framework itself. This facility is the center point around which the program runs.
We suggest that for units that are starting up, a target of 5–10 patients being trained in the initial few years may be sufficient.
We suggest that between 20 and 40 sessions are required for adequate training. Either way, there must be no compromise on the adequacy of the training provided.
| Safety Concerns|| |
We suggest that the enthusiasm for home HD must be balanced with uncompromising safety being offered at all times. Prevention being far better than cure, this obviously boils down to the intensity of the training and the meticulousness of the patients' learning and strict adherence to protocol.
The most common adverse event is inadvertent blood loss. Air embolism is a rarer adverse event and the others are rarer still.
We suggest that patients and caregivers should be taught to tackle complications if they arise.
| Training|| |
We suggest that the training program must be tailored to meet the patient's needs without diluting any of the main aspects and must include operation of the machine for the dialysis session, trouble shooting, vascular access care and management of complications.
| Prescriptions for the Home Hemodialysis Program|| |
We recommend that the following fundamental principles of the home HD prescription are achieved:
- The minimum HD clearance considered adequate is URR >65% and a spKt/V of 1.2 per treatment, three times per week.
- Increasing duration of HD per week is associated with improved survival, better fluid, BP and metabolic control.
- We suggest avoidance of high interdialytic weight gains (> 3–4 kg) and chronic fluid overload by increasing the dialysis frequency
- We suggest avoidance of the long 3-day interdialytic break for improved survival.
We suggest that any of the following home HD prescriptions in current practice at the present time may be used:
- Traditional standard-hours home HD using standard dialysate flow machines
This is similar to in-center HD being done at home 3–3.5 times a week for 3.5–5 h per se ssion
- Alternate-night nocturnal home HD using standard dialysate flow machines
- Alternate-night HD 3.5–5 h per se ssion. Arguably, this is the easiest of the extended-hours HD regimens and the use of consumables is only slightly more than that in regular thrice-weekly in-center HD.
- Traditional short daily home HD using standard dialysate flow machines to maintain 5 to 6 sessions per week with each session lasting 2.5–3.5 h.
- Traditional nocturnal home HD using standard dialysate flow machines
4–6 sessions per week with each session lasting 6–8 h with BFR of 250–350 mL/min and dialysate flow rate of 200–300 mL/min. The dialysate potassium is kept at 3 mmol/L. These patients are prone for hypophosphatemia and the phosphorus must be corrected.
- Low-flow dialysate short daily home HD
5–6 sessions per week with each session lasting 2.5–4 h with BFR of 300–400 mL/min and dialysate flow rate of 83–300 mL/min. The only available model for this prescription is the NxStage system.
- Low-flow dialysate nocturnal home HD
4–6 sessions per week with each session lasting 6–8 h with BFR of 300–350 mL/min and dialysate flow rate of 62.5–166.6 mL/min.
| Key Performance Indicators for the Home Hemodialysis Program|| |
We suggest that every home HD program must as part of its continuous quality initiative, have measurable key performance indicators.
We recommend documentation of training time, failure rates and feedback to improve quality of the delivered service. Clinical effectiveness measures such as home HD technique survival, “near misses” or frequency of intradialytic hypotension episodes, hospitalization rate, adherence to dialysis treatments and medication, fluid, nutrition, clinic attendance, and blood tests, infections, (local/systemic) rate, according to vascular access type (events per 1000 access days), rate of access interventions, according to vascular access type (events per 1000 access days) and rate of bleeding (actual or “near misses”) from the access site, according to vascular access type (events per 1000 access days) are also useful indices of delivered quality.