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Nocturnal home hemodialysis

Nocturnal home hemodialysis (NHHD) benefits in brief

  • Convenient—have your days free
  • Quality—get 2-5 times as much dialysis
  • Gentle—easy on your heart
  • Feel better—more energy, libido, and appetite
  • Less restrictive—easier diet, fewer drugs
  • Time—fewer trips to the clinic

How NHHD works

Hemodialysis (HD) replaces your kidney function by using a dialyzer—a plastic tube filled with hollow fibers—to filter your blood and remove wastes and excess fluid. One needle carries your blood through tubing to the dialyzer, and another needle returns your cleaned blood to your body.

The dialysis machine monitors time, temperature, and pressure. Your blood moves through the system slowly, giving wastes and fluid more time to move from the body into the bloodstream, where they can be removed.

In nocturnal home hemodialysis, you and a partner train for about 6 weeks and learn to do your treatments at home, 3-7 nights a week.

See how daily HHD works. Reused with permission from Kidney School™.

Preparing for NHHD: vascular accesss

To do HD, you need access to your bloodstream through one of three types of vascular access:

  • Fistula - The "gold standard" of access, a fistula is a surgical connection between an artery and a vein, usually in your arm. Because it is entirely natural and completely under your skin, fistulas can last for years, especially if you or a partner are the only ones putting needles in it.
  • Graft - In some cases, your artery and vein are linked with a piece of artificial vein. Grafts are more prone to infection and blood clots than fistulas, and often need "tune-ups" to declot or replace them. Grafts may last a couple of years or more.
  • Catheter - Another way to access the blood is to insert a plastic catheter into a central vein in the neck or chest. Catheters can allow bacteria to enter the body, so it is vital to be careful. Studies have shown higher death rates in people who use catheters, rather than fistulas, for dialysis. For NHHD, a special catheter can be used to reduce the risk of infection. Most catheter infection is caused by touch contamination when needles are inserted into the catheter ports. A catheter with a built-in interlink devise uses screw-type connectors instead of needles. The connector is never open to the air, and never touched with your hands. This type of catheter is changed once a month. A plastic "clamshell" protector snaps over the catheter connection to keep it from coming undone at night while you sleep.

Training

After your access is ready for use, you'll have about 6 weeks of training. Your training nurse will teach you and your partner how to:

  • Set up a treatment room
  • Care for your access and place the needles
  • Figure out how much fluid to remove
  • Run and care for the dialysis machine
  • Store and order your supplies
  • Keep treatment logs
  • Take your blood pressure
  • Follow your diet and fluid limits (which are much more liberal than the diet and fluid limits for in-center hemo)
  • Recognize and report any problems

A nurse will be on call if you need help. Some programs monitor NHHD patients remotely, using a computer and telephone line. Others have found that this is not needed, or use other types of alarms to wake you up in case of a problem.

Availability

Conventional HHD first began in the United States in 1964, and by 1973, 40% of patients did hemodialysis at home. But once many dialysis clinics began to open, HHD became less available. Now, with new, easy-to-use machines on the market (or soon to be released), conventional HHD is coming back.

It can be challenging to find a provider to train and support you, but with demand from patients like you, HHD options are increasing every day. Some people even move to be closer to a center that will allow them to do the kind of treatment they want. Find a dialysis clinic near you.

Cost

For most Americans who qualify (93%), a large part of the cost of dialysis—including conventional HHD—is paid for by the Medicare ESRD Program, no matter how old you are.

Cost for you

Medicare is secondary to your work insurance for the first 30 months of treatment. After 30 months, it becomes primary. Having more than one form of insurance can reduce your out-of-pocket costs.

Your home may need plumbing or wiring changes to do NHHD, and these changes may or may not be paid for by your insurance plan or by Medicare. You'll need to work with the social worker at your clinic to see what can be done in your case. It's also likely that your water and electricity bills will go up.

As hard as it can be, it is very important to read your policy. Some insurance carriers have begun to charge co-pays per treatment for hemodialysis. You may be able to avoid plans like these if you read the fine print.

  • Life Options offers a free 108-page booklet called Employment: A Kidney Patient's Guide to Working and Paying for Treatment. Download it here.

Cost for your clinic

Medicare pays for dialysis with a set fee per treatment, called the composite rate. This rate has lost value, in real dollars, since 1972. Clinics actually lose money on Medicare-only patients for every in-center HD treatment, so it's much better for them—and you—if you have other insurance, too.

Because with NHHD the clinic must provide a machine, ensure water treatment, and train you, they will lose money on you for up to 2 years. You will need to show a real commitment to doing NHHD for them to say yes. After 2 years or so, NHHD may still cost more than in-center HD.

Medicare pays for only 3 treatments per week of HD, so clinics that offer NHHD are often doing pilot studies to see if better patient outcomes will offset the costs. Some machines that reuse the dialyzer and tubing help reduce the cost of NHHD.

Dialysis is the only Medicare-covered treatment that does not have an automatic cost-of-living adjustment. Efforts are underway to fix this—if you'd like to help, go to our Legislative Action Center.

Time

Nocturnal home hemodialysis takes about 6-8 hours each night that treatment is done. Since the machine is in your home, you can decide when to start and finish the treatments.

It takes time to set up the machine for each run and to clean it afterward. For most machines used today, it takes about 45 minutes to set the machine up before dialysis, and about 30 minutes to clean it up after a treatment. To learn about HHD machines, visit our section on dialysis equipment.

Once you're trained and stable for 2 months, you'll have monthly clinic visits to check your lab tests and treatment logs. You'll also need to allow time to check your supply levels, order supplies each month, and receive the shipment. Your machine may need maintenance sometimes, too.

Space needed

You will need a place where a chair, dialysis machine and water treatment tanks (depending on the machine) can be placed with access to water and a drain. You'll also need space to store dialyzers, bottles of dialysate, bleach and disinfectant, syringes, needles, medications, blood tubes, water test kits, and all other equipment and supplies. At this time, you can plan on needing about the space of a standard clothes closet.

Helper tasks

Since your blood is going outside your body during a treatment, it's safest to have someone on hand in case you run into a problem, and most clinics will require it. A helper may place one or both of your needles, fetch things you can't reach when you're hooked up to the machine, give you medications or saline, or even call 911 if necessary.

Most often, a family member or friend trains to be a helper, although some people have hired dialysis nurses or technicians. Medicare does not pay for home hemodialysis helpers. A few clinics pay for them, but this is very rare. In most cases people have paid out-of-pocket for a helper. Some have also offered free rent in a spare room in exchange for a helper, or even traded helping tasks with another HHD patient.

If you are working, you may also be able to write off the cost of a helper as a medical deduction on your taxes. If you are working and getting Social Security disability income, you may be able to submit proof of home helper payment to Social Security as an "impairment-related work expense." Doing this allows you to earn more and still keep a disability check.

NHHD pluses

Some of the benefits of NHHD include:

  • You can dialyze at night and keep your days free. NHHD is a work-friendly treatment.
  • With 24 to 45 hours of dialysis—instead of about 14 hours with in-center HD—people report sleeping and eating better, and having a better libido and more energy.
  • Since you are sleeping during most of the dialysis time, NHHD only takes an hour and a quarter out of each dialysis day for set-up and clean-up.
  • The slow, gentle treatment is easier on your heart, with less cramping and ups and downs than in-center HD.
  • The dialysis diet and fluids may be near-normal with more treatment. You may also need fewer drugs, or lower doses of some drugs. Some people need phosphorus supplements instead of binders.
  • Because you or a partner are the only ones putting needles in your access, a fistula (if you use one) is likely to last longer with fewer problems or trips to the hospital.
  • You'll save time not having to travel to and from the clinic three times a week.
  • Research shows that the more you know about your treatment and the more you do for yourself, the longer you are likely to live.

NHHD minuses

Some of the negatives to NHHD include:

  • Needing a partner to be there for each treatment can put stress on your relationship, or cost you money to hire someone.
  • Training can take about 6 weeks, and you may need to take time off work to do it.
  • You and a partner will need to learn to keep your cool and deal with problems that may arise.
  • If you use a fistula for access, two needle sticks are needed for each treatment, and you or your partner will need to learn to place them. (You can use medication to numb the sites so it doesn't hurt.)
  • If you dialyze with a catheter, you'll need to take care to avoid infection, and your activities (swimming, tub baths, etc.) may be limited.
  • Machine alarms or noises may disturb your sleep. Records kept by the Lynchberg NHHD program suggest that people who dialyze with a catheter can expect about 1.7 alarms each night. People who dialyze with a fistula only have an alarm about every 10 days.
  • It can be hard on you to travel and get in-center HD when you are used to more-frequent treatments. You may find that you don't feel as well. This may change if more centers offer short daily treatments to travelers.

Who is best suited for NHHD?

The most important factor in whether you are suited for NHHD is how much you want to do it. As long as you or a partner can pass the training and learn to place your needles or connect to a catheter, you should be able to do NHHD. Each program that offers NHHD has its own screening methods to be sure that people understand what they are getting into and are willing to commit to the training and the treatment.

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