E-NEPH Archive: Dialysis & Transplantation, Volume 24, Number 10, October 1995 Page 557.
 
 

Slow Nocturnal Home Hemodialysis
Andreas Pierratos, MD, FRCPC; Michaelene Ouwendyk, RN; Robert Francoeur; Lynda Wallace, BScN; William Sit; Stephen Vas, MD, PhD, FRCPC; Robert Uldall, MD, FRCP, FRCPC

Dr. Pierratos, Michaelene Ouwendyk, Robert Francoeur, Lynda Wallace, and William Sit are affiliated with The Wellesley Hospital, Toronto, Ontario, Canada, as was Dr. Uldall prior to his passing away in June of this year. Dr. Vas is affiliated with The Toronto Hospital, Toronto, Ontario, Canada.
 
 

In response to the rising costs of providing renal replacement therapy to an increasingly large dialysis population, our group has been developing a new modality-slow nocturnal home hemodialysis (SNHHD)-whereby patients dialyze 5 to 7 nights a week for 8 to 10 hours while sleeping. Vascular access is established by means of a Cook silastic jugular catheter, and special precautions are taken to prevent accidental disconnection. A trained staff remotely monitors dialysis functions on a computer via a modem. Five patients to date have completed training with the modality and have been successfully performing SNHHD for between 4-14 months. All patients have discontinued their phosphate binders and have increased their dietary phosphate intake. Average predialysis urea and creatinine levels have been significantly reduced to 9.6 mmol/L (26.8 mg/dl) and 486 µmol/L (5.5 mg/dl), respectively. Four out of the 5 patients have reported that they sleep soundly and have experienced greatly increased energy and stamina. Repeated in situ reuse of the dialyzer and blood lines will reduce the patient's work and make SNHHD a very inexpensive modality.

KEY WORDS: home hemodialysis, nocturnal hemodialysis

At present, there are two widely used dialytic methods for treating end-stage renal disease (ESRD), namely in-center hemodialysis and continuous ambulatory peritoneal dialysis (CAPD). Both methods, however, have serious limitations. In-center hemodialysis encourages dependency and is expensive, while CAPD-though it is relatively inexpensive and allows patients to live at home-in many cases provides only borderline or inadequate blood purification.

The use of conventional home hemodialysis has declined steadily because of the stress to the patient and the need for the presence of a partner. Furthermore, home hemodialysis is still more expensive than CAPD. In this paper, we present our early experiences with a new, highly efficient, potentially very inexpensive method of providing home hemodialysis-slow nocturnal home hemodialysis (SNHHD), which is performed during the night while the patient is asleep. SNHHD is achieved through the use of a permanent indwelling internal jugular vein catheter and an appropriately modified hemodialysis machine.
 
 

PATIENTS AND METHODS

Since April 1994, five patients have been recruited for this study: 4 males and 1 female, ages 37-65. They have been trained for SNHHD by a dedicated research nurse (the reasearch coordinator). Three of the patients live with family members, 1 male lives entirely alone, and the female lives with a young child. One of the male patients is a young, insulin-dependent diabetic. The patients recruited for the project were fully informed volunteers who gave consent for the training and therapy, and were free to opt out and revert to their former treatment at any time if they wished.

Vascular access was achieved via a long-term internal jugular catheter developed by this group and manufactured by Cook Critical Care (Bloomington, IN).1,2 To protect against accidental disconnection, the blood lines-which were joined to the Luer-lock arterial and venous limbs of the Cook catheter-were taped and enclosed at the point of connection by a lightweight "locking box" which effectively prevents physical separation of the lines from the catheter limbs even in the unlikely event that they might become unscrewed.

A Fresenius (series H) dialysis machine was modified to produce a dialysate flow of 100 ml/min (6 L/hr). All patients were encouraged to run with a blood flow between 250-300 ml/min. At these blood and dialysate flow rates, there is a 90% equilibration of urea from the incoming plasma to the outflowing dialysate.

All patients are being dialyzed with a low surface area (0.65 m2) polysulfone dialyzer (Fresenius F40) and a dialysate containing a potassium concentration of 2 mmol/L. The patients have been dialyzed for 8-10 hours, 6 nights per week while asleep. All of the main dialysis functions displayed on the front panel of the Fresenius machine are monitored remotely each night via modem at the computer in the SNHHD research office.
 
 

RESULTS

At the time of this writing, the 5 patients have been on SNHHD for periods ranging from 4 to 14 months; they have been allowed to skip dialysis one night a week. All were successfully trained and have had no significant difficulty with the technical aspects of their dialysis procedure. After the first few days of adjustment, 4 out of the 5 patients reported sleeping soundly during the treatment and waking feeling refreshed. Alarms have been infrequent, with arterial insufficiency caused by accidental kinking of the blood line being the most common cause. The fifth patient experienced frequent alarms during the early period of the study which were related to restless sleep, but gradually she adjusted to the treatment and the alarms have become infrequent.

All patients report having greatly enhanced energy and sense of well-being. Three of the males have returned to work full time; the fourth male is a retiree. Hospital admissions have been needed by 3 of the patients, but for reasons unrelated to their dialysis: 1 male required 2 nights in the hospital while he received endoscopic cautery of a bleeding ulcer, another male was hospitalized for 1 night's observation when he had an anginal attack following the removal of a wisdom tooth, and the female patient was hospitalized for 1 night following an endometrial ablation procedure for treatment of menorrhagia.

Vascular Access Problems: Vascular access complications have been few. All of the patients achieved the desirable blood flows of 250-300 ml/min. A bolus dose of urokinase was needed by 2 patients for temporary thrombus obstruction of the catheter.3 These patients are currently being treated with low-dose warfarin. One male patient developed septicemia that was treated with antibiotics and by changing the catheter over a guidewire as an outpatient.4 Two patients had exit-site infections which were successfully treated with antibiotics and by changing their catheters over a guidewire, also as outpatients. None of the infections mentioned above recurred.

Blood Purification: The weekly cumulative amount of uremic solutes removed was estimated by collecting all of the dialysate used over the course of one week. The results were consistently higher, and sometimes three times as high, during SNHHD as during conventional hemodialysis. The weekly average cumulative Kt/V increased from 4.5 on conventional hemodialysis to 7.7 while on SNHHD. All patients are now on completely normal diets, eating anything they like in moderation, and have been able to discontinue their phosphate binders. Plasma phosphate levels have been consistently normal in all patients, as have their serum potassium levels. The average predialysis urea and creatinine levels are 9.6 mmol/L (26.8 mg/dl) and 486 µmol/L (5.5 mg/dl), respectively.

Blood Pressure Control: Two male patients have been able to discontinue most of their antihypertensive drugs, while the others still need to take combinations of antihypertensives.
 
 

DISCUSSION

Slow nocturnal home hemodialysis provides several major advantages. It provides a high level of blood purification-much higher than in-center hemodialysis, conventional home hemodialysis, or CAPD-sometimes leading to near-normalization of some serum parameters.

Despite excellent blood purification, there have been no incidences of the disequilibrium syndrome. Since SNHHD utilizes low dialysate flow and slow fluid removal, the procedure is characterized by the complete absence of intradialytic hypotension. Intradialytic fluid accumulation is also lower than with conventional hemodialysis. Thus, SNHHD is an ideal treatment for patients with cardiac disease who are not candidates for CAPD.

Since SNHHD is performed during the night while the patient is asleep, the treatment does not interfere with the daily activities of the patient and promotes rehabilitation and gainful employment. Despite some sleep disturbances early in the project, the patients seem to have generally undisturbed sleep. They also have a strong feeling of well-being and a strong desire to continue with this form of treatment.

One of the patients who had a previous kidney transplant compared his quality of life on SNHHD favorably to the successful period of his kidney transplant, with the added benefit of no side effects from the immunosuppressive medications. All patients have stated repeatedly that they will never willingly return to their previous conventional in-center hemodialysis regimen.

Frequent and efficient dialysis has allowed the patients to eat freely without the fear of significant fluid gain, hyperkalemia, or hyperphosphatemia. Furthermore, their nutritional status is likely to be normal since no restrictions on protein intake are imposed. Lastly, the longer time on dialysis provided by SNHHD will likely lead to high clearance of middle molecules with the accompanying potential benefits.

SNHHD provides independence for people living alone. Three out of the 5 patients have no partners, yet they feel confident in doing their own dialysis unassisted and alone. They find the remote computerized monitoring of their dialysis to be

reassuring. However, we have no real evidence as of yet that remote monitoring is essential for patient safety.

In view of the dialysis schedule, the cost of SNHHD without dialyzer reuse is prohibitive. The cost of the treatment with reuse of the disposable components will render the cost of the therapy to be comparable with that of CAPD. The one component of the therapy which still has to be put in place is the in situ reuse of the dialyzer and bloodlines. Once that is accomplished, we estimate that the time taken to start and end each treatment will be about 15 minutes and 10 minutes, respectively. Significant progress has been made regarding in situ reuse, and we expect that within the next 6 to 12 months, such reuse of the extracorporeal circuit will be available.

Once in situ reuse is in place, the widespread use of SNHHD would greatly reduce the financial burden of providing dialysis which presently falls on healthcare agencies.

The founder of SNHHD, Dr. Robert Uldall, passed away in June 1995. Dr. Uldall's work on this new approach to dialysis therapy, which he held closest to his heart, will continue with the same drive, enthusiasm, and original energy that he always brought to his research.
 
 

References
1. Uldall PR, DeBruyne M, Besley M, McMillan J, Simons M, Francoeur R. A new vascular access catheter for hemodialysis. Am J Kid Dis 3:270-277, 1993.
2. Mustata S, Less P, Agraharkar M, Muralidharan J, Uldall PR. Further experience with a percutaneously inserted double-lumen silastic catheter for end-stage renal failure patients with refractory vascular access problems. J Am Soc Artif Int Organs, In press.
3. Uldall PR, Besley ME, Thomas A, Salter S, Nuezca LA, Vas S. Maintaining the patency of double-lumen silastic jugular catheters for hemodialysis. Int J Artif Organs 1:37-40, 1993.
4. Carlisle EJF, Blake PG, McCarthy F, Vas S, Uldall PR. Septicemia in long-term jugular hemodialysis catheters: Eradicating infection by changing the catheter over a guidewire. Int J Artif Organs 3:150-153, 1991.
 

© 1995 by Creative Age Publications. All rights reserved. Use is limited to downloading or printing for personal use. Further distribution or reproduction is prohibited. (Posted with permission from Dialysis & Transplantation, Vol. 24, No. 10, 1995.)