What is nocturnal home hemodialysis?

It is dialysis that is performed overnight while the patient and care partner are sleeping.

Who can perform nocturnal home hemodialysis?

The choice to do nocturnal home hemodialysis (HHD) should be a shared decision between you and your doctor. You will need a prescription to perform nocturnal home hemodialysis. You will be trained to perform your treatments at home with a care partner while you both sleep.

What is different about more frequent HHD including home nocturnal hemodialysis?

More frequent nocturnal home hemodialysis treatments are slower and longer, which may be gentler on the heart compared to standard three-times weekly dialysis.1

What are some of the health benefits of more frequent nocturnal hemodialysis?

More frequent nocturnal home hemodialysis is associated with the following (improved health) outcomes:

  • Improved survival – Performing more frequent nocturnal hemodialysis has shown a 5- year survivability comparable to that of patients who have received a deceased donor kidney transplant1
  • Less stress on your heart – More frequent hemodialysis may help reverse a common type of heart damage called LVH (left ventricular hypertrophy)2
  • Better blood pressure control with fewer medications – More frequent hemodialysis may help control blood pressure and reduce the need for blood pressure medications3
  • Much quicker recovery time after treatment – Dialysis patients who convert to more frequent hemodialysis may experience quicker post-dialysis recovery time. In one study, patients experienced up to an 87% improvement in post-dialysis recovery time4
  • Better phosphate control – In a small study, more frequent nocturnal hemodialysis was associated with a reduction of phosphate binders, compared to thrice weekly in-center hemodialysis5

What do you need to do home nocturnal treatments?

  • A prescription from your doctor
  • Training to perform nocturnal home hemodialysis – Your center training nurse will teach you to perform your treatments at home with a care partner while you both sleep
  • Home nocturnal Supplement Guide – Supplemental information to the NxStage System One User Guide
  • Venous needle dislodgment device – This alerts you to a vascular access blood leak with an audible alarm loud enough to interrupt your sleep
  • NxStage fluid detection system – This includes the cycler base, extended cycler base, filter holder, and fluid detection sensor. View more information on NxStage System One Ancillary Devices.
  • Nocturnal therapy usually requires a continuous infusion of anticoagulant. An infusion pump should be used if continuous anticoagulant infusion is desired.

The reported benefits of home hemodialysis may not be experienced by all patients.

Despite the health benefits that home and more frequent hemodialysis may provide to those with chronic kidney disease, these forms of therapy are not for everyone. Please review this information carefully and discuss it with your doctor as you evaluate your therapy options.

Personal and Partner Responsibility
Home hemodialysis with the NxStage System during the day may not require a care partner, provided a physician and a qualified patient agree that solo home hemodialysis is appropriate. Patients performing nocturnal treatments are required to have a care partner. Care partners are trained on and follow guidelines for proper operation. If you choose to do more frequent home hemodialysis, you will be responsible for complying with your dialysis prescription, which may require treatments up to six days per week.

If you choose to do home hemodialysis alone during the day, you will need to take on the responsibility for tasks that would normally be taken care of by staff when in-center. You will need to perform all aspects of dialysis treatment from start to finish, including equipment setup, needle insertions, responding to and resolving system alarms, and system tear-down after treatment. In addition, you must monitor your blood pressure, ensure proper aseptic technique is followed, and follow all the training material and instructions given to you by your training nurses. You will also be trained on and need to know how to respond to health emergencies that might happen during treatment at home, including dizziness, nausea, low blood pressure, and fluid or blood leaks.

Treatment Environment
You must ensure that you have a clean and safe environment for your treatments. You also need to set aside space in your home for the needed supplies.

Risks Associated with All Forms of Hemodialysis
All forms of hemodialysis involve some risks. These may include high blood pressure, fluid overload, low blood pressure, heart-related issues, vascular access complications, cramps, backache, headache, dizziness, nausea, an “off” taste in the mouth, fatigue, fever, chills, joint pain, itching, seizures or sinusitis.

All hemodialysis therapies also involve the use of medical devices that introduce the potential for additional risks including air entering the bloodstream, damage of red blood cells, inflammatory reactions, blood chemistry imbalances, blood loss due to clotting of the blood tubing set or accidental blood line disconnection or other leak, allergic reactions, and excess warming or cooling of the dialysate. In addition, dialysis patients may have other underlying diseases that may, in some cases, make it more difficult for them to manage their hemodialysis treatments.

Risks associated with More Frequent Home Hemodialysis
Studies suggest that patients performing more frequent home hemodialysis may experience slightly fewer complications associated with their treatments and may experience improved clinical outcomes. However, there are certain risks unique to treatment in the home environment. Treatments at home are done without the presence of medical personnel and on-site technical support. Patients (and their care partners, if required), must both be trained on what to do and how to get medical or technical help if needed. When vascular access is exposed to more frequent use, infection of the site, and other access related complications may also be potential risks.

Risks Associated with Solo Home Hemodialysis Therapy
A qualified patient may dialyze alone, without a care partner present (solo home hemodialysis), provided the patient and physician agree that solo home hemodialysis is appropriate. Certain risks associated with hemodialysis treatment are increased when performing solo home hemodialysis because no one is present to help the patient respond to health emergencies. If patients experience needles coming out, blood loss, or very low blood pressure during solo home hemodialysis, they may lose consciousness or become physically unable to correct the health emergency. Losing consciousness or otherwise becoming impaired during any health emergency while alone could result in significant injury or death. Additional ancillary devices and training are required when performing solo home hemodialysis.

Increased Risks Associated with Home Nocturnal Hemodialysis Therapy
The NxStage System may be used at night while the patient and care partner are sleeping. Certain risks associated with hemodialysis treatment are increased when performing nocturnal therapy due to the length of treatment time and because therapy is performed while the patient and care partner are sleeping. These risks include, but are not limited to, blood access disconnects and blood loss during sleep, blood clotting due to slower blood flow or increased treatment time or both, and delayed response to alarms when waking from sleep. Treatment with nocturnal therapy may require adjustments to medications, including but not limited to iron, Erythropoiesis-Stimulating Agents (ESA), insulin/oral hypoglycemics, anticoagulants, and phosphate binders.

References:
  1. Pauly, et. al., used data from two regional nocturnal hemodialysis (NHD) programs and the USRDS from 1994 to 2006. They performed a retrospective matched cohort study comparing survival between NHD and deceased and living donor kidney transplantation (DTX and LTX) by randomly matching NHD patients to transplant patients in a 1:3:3 ratio (177 NHD patients matched to 1062 DTX and LTX recipients). The data showed that after following the population for up to 12.4 years the proportion of deaths of NHD, DTX and LTX was 14.7%, 14.3%, and 8.5% resulting in no difference in the adjusted survival between NHD and DTX. This suggests a possibility that NHD may serve as a preferential bridge or even alternative to transplantation in the current era of organ donation scarcity.
  2. Fagugli RM, Reboldi G, Quintaliani G, et al. Short daily hemodialysis: blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients. Am J Kidney Dis. 2001;38(2):371-376.
  3. Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life. JAMA. September 2007; Vol 298, No. 11, 1291 – 1299. (Nocturnal)
  4. Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. Am J Kidney Dis. 2010;56(3):531-539.
  5. FHN Trial Group, Chertow, G.M., Levin, N.W., Beck, G.J. et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010; 363: 2287–2300.