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Hemodialysis at Home

Advances in technology allow patients with kidney failure to manage treatment on their own schedule

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When a person's kidneys fail, their body experiences a buildup of harmful wastes, and treatment is required. Hemodialysis, a complex therapy that eliminates extra fluid and waste by filtering a few ounces of blood at a time, is a lifesaving treatment for hundreds of thousands of people in the U.S. with kidney failure.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, most patients adhere to a strict hemodialysis treatment schedule of visiting a clinic three times per week for three or more hours each visit.

However, advances in technology have made home-based hemodialysis more feasible in recent years, and patients are finding numerous benefits to home treatment.

How Does It Work?

New machines developed over the past decade have enabled patients to travel and perform home dialysis, noted Sheila Doss-McQuitty, BSN, RN, CNN, CCRA, western region vice president of the American Nephrology Nurses Association.

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Though the equipment may vary, home hemodialysis is performed with the same procedures as in-center hemodialysis, she said. Dialysis centers provide the equipment and support for home patients. These centers then bill the payment provider, such as Medicare or private insurance companies, for the services.

"Patients may be required to pay any amount not covered by the payment provider," explained Doss-McQuitty. "Most commonly, the patient is enrolled in the ESRD Medicare program and 80% of the payment is covered. Patients will then have a secondary insurance to cover the remaining 20%."

While training periods vary from provider to provider and patient to patient, they most often range from six to eight weeks.

"If a patient is working, this length of training may present challenges, but most facilities will attempt to accommodate patients. If a patient is able to self-cannulate at the time training is initiated, the length of training can be decreased," she said.

Jennifer Harper, RN, CNN, home dialysis coordinator at Ocean Medical Center in Brick, N.J., noted home hemodialysis treatments are shorter, averaging two and a half to three hours, five to six days a week, in the home setting.

Ocean Medical Center provides training and equipment for home hemodialysis with a training period approximately one month long. 

"Patients with their caregivers must be able to perform the treatment safely by themselves in the clinic before being discharge to the home," Harper said.

All patients must have a caregiver present during their treatment at home for backup assistance.

Advantages of Home Dialysis

Shari Meola, RN, CNN, clinical coordinator for the Hortense and Louis Rubin Dialysis Center Inc. in New York, believes there are many advantages to home hemodialysis.

"First, you can do it on your schedule. You do not have to travel to the center after your training except for once-a-month clinic visits with the multidisciplinary team," she said.

Other advantages to home-based treatment include a liberalized diet and minimal fluid restrictions when nocturnal or extended therapy is practiced. In addition, in-center treatment insurance copays are decreased to one copay per month.

"Patients also benefit from being involved and in control of their treatments. We see that patients feel better within the first week of daily treatments, they state they have more energy, foods tastes better and they notice they have clearer mentation," Meola said.

Doss-McQuitty concurred that home hemodialysis provides a variety of advantages when compared to in-center hemodialysis.

"Home hemodialysis allows patients to fit their dialysis into their lifestyle instead of being required to meet the schedule established by a dialysis center. They are able to maintain a more 'normal' lifestyle while receiving their dialysis therapy. The schedule of their dialysis can be adapted day-to-day to allow the patient to work and participate in family and child events," she remarked, noting that patients frequently comment home hemodialysis has given them their lives back.

By having the ability to perform the dialysis procedure themselves, patients are empowered to control their healthcare, and an empowered patient is more likely to comply with the medical regimen prescribed by their healthcare providers, Doss-McQuitty said.

"These patients understand the dialysis procedures and the effects their compliance with these procedures have on their outcomes," she said.

Not for Everyone

While there are plenty of advantages to home dialysis, this type of treatment doesn't work for everyone. Joan Fox Rose, MA, RN, said her husband used to dialyze overnight, which was supposed to give him more time to live his life without the need to follow a four-hour, three-times-per-week treatment schedule at the dialysis center.

"My husband couldn't sleep while on treatment. Every noise the machine made kept him awake," she recalled.

Furthermore, other tasks a spouse takes on before and after a treatment, such as the process of getting the needle in place, proved frustrating.

"The treatment tended to take over our lives," Rose said.

When her husband developed a MRSA infection in a heart valve, they decided to discontinue home dialysis treatments. Currently, he is getting nocturnal dialysis treatments at the dialysis center where professional staff are on hand to set up and monitor his machine and his response to treatments.

Other patients just don't have a desire to bring their disease into their home, Harper said.

"Some are afraid of sticking themselves with needles and dealing with the blood, and others have said that they are afraid something may happen to them while on dialysis at home," she remarked.

The risks to home hemodialysis are the same as in-center hemodialysis. Any of the following complications can occur: cardiac symptoms, cramping, itching, insomnia, anemia, vascular access problems, bone disease, fluid overload, depression and infection.

"Patients who perform home hemodialysis five or six days a week have fewer to none of the above symptoms, which is why many of them are willing to take on the responsibility of their dialysis therapy in the home," Harper said.

All patients participating in home dialysis are properly trained to self-cannulate and are prepared to troubleshoot problems that may occur during dialysis. 

'Why We Do What We Do'

While every facility will have different criteria for who is a good candidate for home hemodialysis, most important is a patient who desires to be on home dialysis, has an adequate home setting and support system, and has the ability to perform the procedures.

"It is essential that the burden of the therapy be explained to both the patient and the family and that family members are provided an opportunity to voice their concerns and hesitations," Doss-McQuitty said. "Many patients who have previously been non-compliant with their in-center therapy have been able to successfully perform home hemodialysis. The evaluation process is extremely important."

She believes home hemodialysis is increasing in popularity with physicians for several reasons - more patients are beginning to voice their desire for this therapy and governmental agencies are supporting and encouraging home therapies. As more physicians become familiar and the dialysis providers offer both training and support of home hemodialysis, the prevalence of the therapy will increase.

While there are no randomized controlled trials to support the improvement in outcomes and the evidence available is anecdotal, Doss-McQuitty said patients do "extremely well" on home hemodialysis.

"This option should be made available for patients. A patient's children recently told us, 'Thanks for giving us our dad back,' which is why we do what we do for our patients," she concluded.

Beth Puliti is a freelance writer.


 

Thank you for an informative and accurate article! For those who want to learn more about the various types of home dialysis, the non-profit Medical Education Institute offers the Home Dialysis Central website, at http://www.homedialysis.org.

Dori Schatell,  Executive Director,  Medical Education InstituteFebruary 22, 2013
Madison, WI




     

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