How Does Hemodialysis Work?
- Hemodialysis uses an artificial kidney, or dialyzer, and a hemodialysis machine
- A special blood access called a fistula, graft, or central venous catheter (CVC) is created by a surgeon.
- At the start of each treatment, two dialysis needles will usually be put into the access. The other end of the dialysis needle will then be connected to tubing that will connect to the hemodialysis machine and dialyzer.
- One of the dialysis needles takes blood away from the body, while the other returns blood to the body
- During the treatment time, blood is continuously pumped from the access, through the tubing to the machine, and through the dialyzer. The dialyzer acts as a filter for the blood, removing waste products and extra fluid. Throughout the treatment time, clean blood is then returned to the patient.
- At any time during the treatment, there is only about 1 cup of blood outside of the body flowing through this circuit. At the end of the treatment, blood is returned to the patient.
More About the Hemodialysis Access
- A fistula is a connection between an artery and a vein. It should be healed and ready to use in about 6-8 weeks once the vein has expanded.
- A graft is artificial tubing that connects an artery to a vein. It is placed under the skin. This is healed and ready to use in about 3-4 weeks.
- A CVC catheter is used when dialysis is needed immediately, or if there is a problem with the fistula or graft. A tube, or catheter, is placed into a vein near the chest or neck. It is removed once the permanent access is ready to use.
- A fistula or graft needs time to heal before it can be used, so the doctor may recommend having access surgery 2 to 3 months before dialysis is expected to start
Performing Home Hemodialysis
- Hemodialysis can be done in the comfort of the patient’s home. A partner may be necessary to do home hemodialysis (HHD), but some patients are able to manage the treatments on their own during waking hours (Solo HHD).
- A hemodialysis machine and supplies will be sent to the patient’s home.
- The clinic nurse will provide the patient (and care partner) with about 3-4 weeks per-protocol of training to learn to insert the dialysis needles, perform the treatment, troubleshoot, and handle emergency situations.
- Home therapy staff and technical support are available by phone to support patients as needed. It is still necessary to visit the healthcare team regularly to be sure the dialysis is keeping the patient healthy.
Home Hemodialysis Modalities
There are several options to individualize home hemodialysis.
The physician will prescribe the length of time and number of days needed for dialysis, based on the patient's medical condition. Then, with the help of the healthcare team, an option can be chosen that will work best for their lifestyle.
- Treatments are usually 3 times each week
- Treatments are typically 3-5 hours
- Treatments are done during the day
More Frequent HHD*
- Typically done 5-6 times per week.
Many patients report that more frequent HHD may offer the following health and quality of life benefits when compared to conventional, three times per week, in-center hemodialysis:
- Better blood pressure control with fewer medications – More frequent hemodialysis may help control blood pressure and reduce the need for blood pressure medications13
- Less stress on the heart – More frequent hemodialysis may help reduce a common type of heart damage called LVH (left ventricular hypertrophy)1
- Improved 5-year survivall2
- Fewer medications3
- More energy and vitality4
- Improved appetite with fewer fluid and diet restrictions5
- Increased likelihood to be on the transplant list6
- Improved post-dialysis recovery time7
- Improved sleep quality8
- Increased flexibility to go to work or go to school9,10
- Performed overnight while the patient and care partner are sleeping.
- A slower and longer treatment that more closely resembles healthy kidney function, which may be gentler on the heart compared to standard three-times weekly dialysis.11
- 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 transplant11
- 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 time7
- Better phosphate control – In a small study, more frequent nocturnal hemodialysis was associated with a reduction of phosphate binder need, compared to thrice weekly in-center hemodialysis1
- Allows for an individual to do HHD during waking hours without a care partner
- Provides an opportunity for greater control, ownership of self-care, increased independence, and flexibility in treatment scheduling.
On-site HHD at Skilled Nursing Facilities
- On-site home hemodialysis is a growing movement in which dialysis providers and Skilled Nursing Facilities (SNF) are partnering to offer SNF patients requiring dialysis with on-site treatments in the SNF where they reside.
Things to Consider About Home Hemodialysis
- HHD is considered a self-care treatment. The patient and care partner are responsible for preparing, performing, and monitoring the treatment.
- Treatment schedule may be more flexible.
- No travel required to a dialysis center for treatments.
- May allow patient more independence.
- Visits to the clinic are required every 3-4 weeks to meet with the doctor and healthcare team to check laboratory values and see how the treatments are going.
- Not all facilities offer HHD.
- A 4+ week training program helps to prepare the patient and care partner to complete self-care at home.
- Space is needed for a monthly delivery of supplies.
Home Hemodialysis Risk
Users should weigh the risks and benefits of performing home hemodialysis with NxStage systems.
- Medical staff will not be present to respond to health emergencies that might happen during home treatments, including, among other things, dizziness, nausea, low blood pressure, and fluid or blood leaks.
- Users may not experience the reported benefits of home, more frequent, or nocturnal hemodialysis with the NxStage systems.
- The NxStage systems require a prescription for use.
Users will be responsible for all aspects of their hemodialysis treatment from start to finish.
Medical staff will not be present to perform home treatments. Users will be responsible for, among other things, equipment setup, needle insertions, responding to and resolving system alarms, system tear-down after treatment, monitoring blood pressure, ensuring proper aseptic technique is followed, and following all the training material and instructions that nurses provide.
Users will need additional resources to perform home hemodialysis.
- Users will need a trained care partner to be present during your treatment at home (unless their doctor prescribes “solo/independent” home hemodialysis, described below).
- Users must have a clean and safe environment for their home treatments.
- Users will need space in their home for boxes of supplies necessary to perform home hemodialysis with NxStage systems.
Certain forms of home hemodialysis have additional risks.
- If a doctor prescribes home hemodialysis more than 3 times a week, vascular access is exposed to more frequent use which may lead to access related complications, including infection of the site. Doctors should evaluate the medical necessity of more frequent treatments and discuss the risks and benefits of more frequent therapy with users.
- If a doctor prescribes “solo/independent” home hemodialysis without a care partner during waking hours, risks of significant injury or death increase because no one is present to help users respond to health emergencies. If users experience needles coming out, blood loss, or very low blood pressure during solo/independent home hemodialysis, they may lose consciousness or become physically unable to correct the health emergency. Users will need additional ancillary devices and training to perform solo/independent home hemodialysis.
- If a doctor prescribes “nocturnal” home hemodialysis at night while the user and a care partner are sleeping, risks increase due to the length of treatment time and because therapy is performed while the user and a care partner are sleeping. These risks include, among other things, 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. A doctor may need to adjust users’ medications for nocturnal home hemodialysis, including, among other things, iron, Erythropoiesis-Stimulating Agents (ESA), insulin/oral hypoglycemics, anticoagulants, and phosphate binders.
Training to do Home Hemodialysis
- HHD clinic nurses teach patients (and care partners) how to do HHD and to troubleshoot.
- The training time varies and is customized to meet individual needs and be sure the patient and care partner are ready to do HHD at home.
- Some patients can do solo treatments with prescription during waking hours and do not require a care partner. At the end of the training, the patient/care partner will begin doing their treatments at home.
- The patient will learn how to operate dialysis equipment, access blood, monitor vital signs, administer HHD prescription, troubleshoot, and handle emergency situations.
- Requires a clean space to do treatments at home. Supplies are typically delivered monthly, and need to be kept in a clean, dry area.
"I was not going to be a passenger in this car called life. I had to get in the driver's seat. It was time to take control of my life."
Roshanda, Former PD Patient, Current Solo More Frequent HHD Patient and NxStage Patient Advocate
- The 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.
- U.S. Renal Data System, USRDS 2015 Annual Data Report: Table 6.3. and matched NxStage patient data on ﬁle.
- Bakris, G.L., Burkart, J.M., Weinhandl, E.D., McCullough, P.A., and Kraus, M.A. Intensive hemodialysis, blood pressure, and antihypertensive medication use. Am J Kidney Dis. 2016; 68: S15–S23.
- Finkelstein FO, Schiller B, Daoui R, et al. At-home short daily hemodialysis improves the long-term health-related quality of life. Kidney Int. 2012;82(5): 561-569.
- Lerma EV, Weir MR. Henrich's Principles and Practice of Dialysis. Chapter 8: Long and Daily Hemodialysis, 2017. Print.
- Weinhandl ED, Liu J, Gilbertson DT, Arneson TJ, Collins AJ. Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. JASN. 2012;23(5):895-904.
- Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive symptoms and post-dialysis 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.
- Jaber, B.L., Schiller, B., Burkart, J.M. et al, Impact of short daily hemodialysis on restless legs symptoms and sleep disturbances. Clin J Am Soc Nephrol. 2011;(6):1049–1056.
- Purnell TS, Auguste P, Crews DC, et al. Comparison of Life Participation Activities Among Adults Treated by Hemodialysis, Peritoneal Dialysis, and Kidney Transplantation: A Systematic Review. Am J Kidney Dis. 2013;62(5):953-973.
- Walker RC, Howard K, Morton RL. Home hemodialysis: a comprehensive review of patient-centered and economic considerations. Clinicoecon Outcomes Res. 2017;9:149-161.
- Pauly, et. al., used data from two regional nocturnal hemodialysis (NHD) programs and the USRDS from 1994 to 2006.
- 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.
- 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)
- Raimann JG. Handbook of Dialysis Therapy. Vol 19. 5th editio. (Daugirdas JT, Blake PG, Ing TS, eds.). Elsevier; 2017. doi:10.1016/C2014-0-03172-3
About In-Center HD
- Healthcare professionals prepare, perform, and monitor the treatments.
- Done as an outpatient treatment at a clinic or hospital. There are many clinics and hospitals that offer hemodialysis.
- Travel to the clinic for treatment is needed and the patient leaves after treatment is completed.
- Schedule for treatment is typically set by the clinic.
- The doctor will prescribe the number of days and hours needed for the treatments.
- Most people do 3 treatments per week for 3-4 hours.
In-center HD Modalities
There are 3 forms of in-center hemodialysis:
- Treatments are usually 3 times each week
- Treatments are typically 3-4 hours
- Treatments are done during the day
- Treatments are done during the night while the patient sleeps at the clinic
- Treatments are generally done 3 times each week
- Treatments usually take about 8 hours
- Not available at all clinics
- Patient participates in the treatment by placing their own needles or preparing the dialysis machine for treatment
- The healthcare team will monitor the treatment
- May be done with both conventional and nocturnal dialysis
- Not available at all clinics
Things to Consider About In-Center Hemodialysis
- Many clinics and hospitals offer hemodialysis.
- Treatments are completely managed by healthcare professionals.
- The schedule is set by the clinic.
- Travel to and from the clinic is required.
- There are days off from dialysis; typically go to treatment 3-4 times per week.
- Other patients are there to socialize with.
In-Center Hemodialysis Risk
The risks associated with hemodialysis treatments in any environment include, but are not limited to, high blood pressure, fluid overload, low blood pressure, heart-related issues, cramping, dizziness, nausea, and vascular access complications. The medical devices used in hemodialysis therapies may add additional risks including air entering the bloodstream, and blood loss due to clotting or accidental disconnection of the blood tubing set.
Patients should adhere to dietary restrictions and dialysis prescription.