HH started in the early 1960s in Boston & London. Current studies since that time have shown better survival & quality of life for ptns on conventiona
Literature review current through: Jan 2022. | This topic last updated: Feb 26, 2020.
HH started in the early 1960s in Boston & London. Current studies since that time have shown better survival & quality of life for ptns on conventional, thrice weekly HH in comparison with ptns on other DX modalities. In regard to the cost, it has significant less costing than conventional in-center HDX that led some authors to believe that HH is better as compared to KTx. Despite the given benefits, the % of prevalent DX ptns with ESRD on HH in the US has increasingly dropped from the start of the Medicare ESRD program in 1973 until 2002, to became 0.57 %. Similar alterations have seen in other countries. Since 2002, there has been a gradual rise in the quantity and % of all US DX ptns on HH; by 2008, 3826 ptns (1.09 %) on HH, have been reported and along 2010 suggested that the quantity of ptns was 5000-6000 that reflecting a rising interest in HH. Considering the USRDS 2013 data for incident 2011 ptns, total HH ptns have been rising but mainly related to the significant rising in ptns on continuous cycler PD. Actually, there’re several barriers to ptns choosing the home modality.
The quantity of ptns ttt with any home DX modality (HDX or PD) has declined along 10 ys from , when the trending starts to change. By 2010, a large rise in all HH has been observed, with mostly new ptns on PD. Moreover, there was also clear rise in HH by , though < 1500 ptns out of about 13,000 ptns have chosen the home modality. The entire therapy of HH still diminished. Among incident ESRD ptns, only 9.1 % of home DX ptns were maintained on HH in 2013.
Worldwide, there’s little or no HH, except in few numbers of high-incomed countries with an annual per capita national income > US $10,000, and, until recently, the number of home DX ptns had been mostly dropped in these areas. In 2006, there was chance for significant extension in HH therapy in many countries. Such extension has been observed in the US and elsewhere. A DX economic has been developed by an international group of nephrologists observed that the increasing home-related modalities (including PD) may help addressing the growing DX burden all over the world. New HH programs have been addressed in Turkey, India, China, and Hong Kong.
REASONS FOR THE DROP IN HH
The current lack of HH modality for ESRD therapy in the US may be attributed to:
However, HH of increasing attention as a valuable modality for several reasons:
The studies assessing ptns’ survival on conventional HH reported general survival rates of almost 90 & 50 % at 5 & 15 y.s, resp.. Although these reports were proceeded by authors who’re favoring using this modality, the following data from a report using the USRDS database are corroborating these findings:
This improved survival, however has also been found outside the US e.g.,
Ptns maintained on a such DX modality at home as those who’re dialyzed in-center, the reasons of improved survival are not well certain (except for selection bias). Blagg & Scribner alarmed the need for DX ptns to keep their independency avoiding the syndrome of "learned helplessness". Ptns exerting enough responsibility and mostly know about their disease feel "in charge" of their own ttt achieving more favorable outcome. Similar psychological factors may play a robust role in HH ptns. Such ptns may also be less likely to dedicate portions or timing from their therapy, esp. those on overnight DX.
Prolonged conventional DX, thrice weekly, is associated with improved survivals e.g., among the best ptn survival findings in the world are those from Tassin, France showing the remarkable benefits of thrice weekly, 8-h DX in center or at home. After 5 ys, ptns showed no evidence of progressive nutritional deficits observed in HDX (HEMO) trial. In Australia, many DX centers have adopted HH that’s synonymous with extended-h.s DX due to survival, physiologic, quality-of-life, social, and economical benefits.
More benefits can be expected with more frequent short daily and/or long nightly HDX, both of them can be mostly easier at home. Benefits may include more adequate DX with a higher Kt/V, better BP management with fewer or no agents, regressed LVH and reduced inflammatory markers, significant improvement in removing PO4 and B2 microglobulin (esp. with nocturnal HDX), subjective improving in ptn wellbeing both during and between sessions, better nutrition and quality of life.
However, considering the increased supplies, more frequent HDX usually costs more, even if at home. So, it should be realized that overnight nocturnal HDX 3 times a week can provide the double as many h.s of DX/week compared with conventional in-center HDX as the practice in the US, less costing, and better outcome.
Long, alternative-night HDX at home/center is a marvelous compromise. It removes the weekly 2-day gaping between sessions at weekends, and it has been observed that there’s a threefold raising risk for sudden death in the 12 hs before DX after the weekend. While it’s not as efficacious as overnight HDX 6 nights a week requiring more UF, it induces relatively better PO4 control; however, it cannot eliminate PO4 binders requirement. One report: it can manage the biochemical agents related to bone mineral metabolism almost like nightly and daily short DX. Considering costing and consumable requirements are nearly less than that with nightly and daily HDX, extension of this regimen should be considered.
The 2015 KDOQI guidelines: considered home long HDX 3-6 nights/week, recommending that ptns considered for this modality should be informed about the related risks that may include:
1) Potential rise in access complication(s),
2) Higher burden for the caregiver(s), &
3) Rapid loss of the residual kidney function.
MECHANISM OF BENEFITS
Prolonged, thrice-weekly DX sessions and/or more frequent HDX have variable impacts that could be contributing to the clearly improved outcome. One crucial difference is the ameliorated abnormal physiological cycling of body water, blood osmolality, and total body solutes that seen with intermittent/intense conventional DX modalities. Short/long daily DX almost invariably resulting in clearer ptn benefits compared with overnight HDX 3 times/week, and, at least with short frequent DX, this’s not necessarily related to the higher weekly DX dose. Despite the developed Kt/V urea has considered the common mathematical tool to calculate the DX dose with more frequent sessions, PO4 and middle-molecule removal are mostly more crucial than small-molecule elimination and augmented with increased weekly DX dosing.
Where lab profiles to estimate removal of B2-microglobulin are not currently available, rather than relying on the Kt/V, the quality of DX may be best assessed from ptn outcome and clinical Sms, e.g., effective DX therapy may be best proved by a better quality of life that’s partially defined by lowered needs for EPO and anti-HT drugs, better appetite with absent fatigue and pruritus.
POSSIBLE TECHNIQUES TO REVERSE THE DROP IN HH
Several obstacles must be overcome to augment the % of ESRD ptns amenable for HH modality and more frequent DX dose. The suggested steps that nephrologists can admit to reverse the declining trend may include:
Morbidity/MR from DX is generally have declined only slightly among ptns in the US, despite the implemented DOQI guidelines and improving Hct, serum albumin, & Kt/V values. Moreover, the HDX (HEMO) study declared that thrice weekly HDX, augmenting the dose of DX above DOQI-recommended guidelines or with high-flux membranes had no significant impact on hospitalization or ptn MR. MR still compares unfavorably with that of Japanese, Western European, and Australian HDX ptns.
BARRIERS TO EXTENDED USE OF HH MODALITIES
There’re multiple barriers to use HH modalities:
It’s possible that HH declining can be reversed now that the barriers have been identified. HH can provide several benefits that there’s considered chance for more DX delivery with improved outcome. To overcome these hurdles, it’s necessary for the clinicians to take a step with staff and ptns choosing in advance those who’re likely candidates for one of the HH modalities.
To continue the improvement, recent approaches/techniques have to be introduced to provide HH delivery of more frequent modules and more physiological DX at home. A variety of machines dedicated for HH have been admitted or are under evolution:
Every system is usually focusing on the introduction of several program schemes to induce easier/safer procedure, including:
1) Better computer monitoring,
2) Better sterilization technique, &
3) The feedback designing.
Other areas of interest are related to wearable artificial kidney and the implantable artificial kidneys. The 1st is developed by some small companies, and at least one of them is undergoing clinical assessment. The biggest inquiry with the wearable device is blood access, and so 2 groups are designing wearable PD devices.
The evolution of an implantable artificial kidney based on the University of Michigan Renal Assist Device has been admitted for many years. It’s not expected to be exposed for clinical testing for several years. Finally, it’s important to highlight that PD is also a variety of home ttt that may play a wider role in the future.
Every member in the DX team must become advocated for HH and for more frequent DX if it became feasible. Until that time, conventional overnight thrice weekly or alternate-night HDX, either at home or in a center, is suggested to be an optimal ttt schedule. By the end of the year 2007, 841 ptns were on conventional HH thrice weekly, 302 on alternate nights, 2396 on short daily, and 225 were on HH 5-6 nights per week.
Despite the difficulty to receive potential ESRD ptns early in the course of RF, nephrologists must stress upon their colleagues that ptns on stage 3 & 4 CKD should be referred as early to teach them how to manage their disease and to inform them about the benefits of HH, more frequent HDX, PD, and Tx.
This information may help reducing ptn fear and depression. It will also make it possible for ESRD ptns to manage their illness more realistic and provide them the opportunity to select the best module of DX ttt. The website, Home hemodialysis Central, is a marvelous resource for ptns interested in home DX.
Trials that reported better ptn outcome with HH and more frequent HDX highlight the vitality of ptns information about various modalities of HDX feasible to them and, in particular, the benefit (s) of HH and more frequent HDX. Clinicians in the US & Canada believe that home DX therapy is underused and that % of all HDX ptns are candidate for ttt by HH. A 2007 survey of 6595 delegates at 5 international HDX & nephrology conferences (57 % physicians & 28 % nurses) found that they’re mostly considering frequent home or self-care HDX the best long-term modality. Furthermore, at least 2 informal polls of nephrologists asked what ttt they would prefer, if Tx was not feasible, found the vast majority would prefer HH, whether they had home DX ptns or not.
So, nephrologists and the entire DX staff should not let their emotions or economic requirements deciding the DX modality if there’s any chance of the ptn choosing HH. This modality of ttt is still the best option for many cohorts of ptns than already had the opportunity for it.