“You need dialysis” are words nobody wants to hear. But today kidney failure doesn’t have to mean driving to and from a clinic three times a week and having a lesser quality of life. Hemodialysis (HD) can safely be done in the privacy of your home in two new ways: daily and nocturnal home HD, both of which can help you feel better and live longer.

The Kidneys: Your Scales of Justice

Healthy kidneys balance body water and salts (like sodium, potassium, and calcium).  The kidneys’ nternal sensors check each drop of blood. Too much water? It’s reabsorbed.  Not enough?  The kidneys release renin to constrict blood vessels and raise blood pressure. Extra water, salts, and toxins are shuttled to the bladder as urine.  Kidneys work 24 hours a day, seven days a week to maintain this homeostasis (the body’s constant state of inner equilibrium), and the closer dialysis gets to keeping this delicate balance, the better you’ll feel – and the longer you’ll live.  

Standard Dialysis

In the United States, 92 percent of people with kidney failure get standard, in-center HD treatments: just three to four hours, three times a week, with little choice of time slot. This schedule creates a two-day gap with no treatment at all.  Studies have found that heart attacks and sudden heart death are twice as likely on the day after the two-day gap than any other day of the week.,

With short dialysis three times a week, each treatment is quite harsh. Fast water removal can cause sudden blood pressure drops with painful muscle cramps.  Some people feel fine afterward, but others are “washed out,” weak, and tired for as long as six hours.  The ups and downs of three times a week HD are hard on the heart.

Finally, standard HD does a good job removing small molecular-weight toxins.  But it doesn’t remove enough of the “middle molecules” that cause longer-term problems like neuropathy – already an issue for those with diabetes – and bone and joint damage.   

Daily HD:  A Better Way

Daily HD is an option you learn to do at home five to seven days per week for two to three hours at a time, on your own schedule.  Training takes three to four weeks.  The clinic trains you and provides the machine (you don’t have to buy it) and 24-hour phone backup.  Many programs require a partner.  Depending on how much you can do, your partner may need to stay home in case you need a hand, may do the whole treatment or something in between. Anyone who can drive a car can learn to do home HD.  

A new machine called the NxStage System One makes daily HD possible.  The size of a microwave oven (75 lbs.), the System One can go as luggage on an airplane or cruise, in the trunk of a car, or in a camper.  Bagged dialysis fluid can be shipped to a vacation spot.  At home, a coffee table-sized unit makes fresh fluid every three days, and the System One sits on top.

Daily HD has no two-day gap.  Daily treatments help control blood pressure without drugs in most cases. And the diet can be much closer to your normal diabetic meal plan without extra limits.  People who do daily HD say they have more energy and a better quality of life.  (Note:  Medicare pays for three HD treatments per week; you may need additional insurance to get daily HD).

Nocturnal HD:  “Cadillac Dialysis”

When dialysis first started in the United States in the 1960s, it was done at night so people could sleep through the treatments and go to work the next day. Today, doing three to six nightly treatments of eight hours each allows a more normal diet, better sexual function, more energy, no blood pressure pills, and days free for work, family or other tasks. The long, gentle treatments are easy on the heart and do an excellent job of removing “middle molecules,” which can help prevent problems down the road.  

Worried about sleeping with your blood outside of your body?  “Bedwetting” alarms wake you up if even a drop of blood is spilled.  Most people who do nocturnal HD do learn to relax and sleep through it after a few weeks.

Training takes six to eight weeks and many centers require a partner. As with daily HD, you don’t need to buy the machine – the clinic provides it – and you have 24-hour phone backup. Some clinics monitor the treatments over the internet. A standard machine may be used (which may require plumbing and/or wiring changes to your home) or some clinics are testing the NxStage System One for nocturnal use.  Nocturnal HD done three times per week or every other night is covered by Medicare.

There’s No Place Like Home

If home HD is so much better, why don’t more Americans with kidney failure use it?  Because most of them have never heard of it.  Of the 5,000 or so U.S. dialysis centers, only about one in 10 offers home HD, though this number is growing quickly as more people learn about home HD and ask for it.

Once you finish training for home HD and are confident enough to go home, you only need to visit the clinic once a month.  So, a home clinic can be as far away as you’re willing to drive once a month.  To find a center that trains people for home HD – as well as information about home options, stories of people who use these treatments, and other information and support – visit Home Dialysis Central (www.homedialysis.org).

Protecting Your Kidney Function

The National Institutes of Health say that 30 years ago, one out of three people with diabetes developed kidney failure.  Today, that number has dropped to just one in 10.  You can improve your chances of keeping healthy kidneys if you: 

• Keep tight control of your blood sugar
• Ask your doctor to test your urine for tiny amounts of protein in your urine (microalbuminuria) once a year – the presence of protein means that damage may be starting
• Keep your blood pressure in the target range (125/75) – ask your doctor about blood pressure pills called ACE-inhibitors or ARBs, which protect the kidneys in people with diabetes
• Quit smoking if you smoke – studies show that smoking makes kidney disease progress faster
• Avoid heavy use of non-steroidal anti-inflammatory (NSAID) pain killers, like Aleve® or Advil®. 
• Ask for special precautions if you need to have an X-ray dye test – the dye can harm your kidneys. 
  

Karnik JA, Young BS, Lew NL, Herget M, Dubinsky C, Lazarus JM, Chertow GM. Cardiac arrest and sudden death in dialysis units. Kidney Int. Jul;60(1):350-7, 2001.

Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int. Apr;55(4):1553-9, 1999.

http://www.nih.gov/about/researchresultsforthepublic/kidney.pdf