Six years of experience with nightly home hemodialysis access.

BACKGROUND: Lynchburg Nephrology Dialysis Incorporated started its nightly home hemodialysis (NHHD) program in September 1997. PURPOSE: The purpose of this study was to evaluate episodes of exit-site infections, catheter sepsis, and safety and longevity of accesses for patients doing NHHD. METHOD: If internal jugular (IJ) catheter was chosen, the patient was started on 2 mg coumadin per day when catheter was placed. If catheter malfunctioned, it was blocked with a thrombolytic agent and coumadin was adjusted to meet a goal international normalized ratio (INR) of 1.5 to 2.25. If the problem persisted, the catheter was exchanged. For catheters, a threaded lock cannula (BD InterLink device, BD) was used to prevent air emboli and infections and a locking device was used to prevent disconnects. If arteriovenous (AV) fistula was used, four buttonholes were established using 16-gauge needles. If AV graft was used, patients were taught the rope ladder cannulation technique using 16-gauge needles. RESULTS: As of September 1, 2003, 45 patients have completed training and have performed 27,063 treatments at home. Total catheter time at home was 930 months. Total AV fistula and AV graft times at home were 190 and 20 months, respectively. Upon completion of training, 34 patients were using tunneled IJ catheters, 10 were using AV fistulas, and 1 was using an AV graft. The IJ catheter exit-site and sepsis infection rates were 0.35 and 0.52 episodes per 1000 patient-days, respectively. Mean catheter life was 8.5 months with the longest being 66.7 months and the shortest being 0.2 months. The AV fistula and graft exit-site and sepsis infection rates were 0.16 and 0 episodes per 1000 patient-days, respectively. Catheter complications included one episode of disconnect due to patient's failure to use the locking device, one episode of central stenosis, and one episode of intracranial hemorrhage, due to prolonged INR, with resolution of symptoms. CONCLUSION: Data support the fact that tunneled IJ catheters, AV fistulas, and AV grafts are effective and safe permanent accesses for patients on NHHD.

Nightly home hemodialysis: five and one-half years of experience in Lynchburg, Virginia.

BACKGROUND: Lynchburg Nephrology Dialysis Incorporated initiated a nightly home hemodialysis (NHHD) program in September 1997. As of April 30, 2003, 40 patients had completed training; 28 patients were at home and 2 patients were in training. The average age of the patients at the initiation of the home-based therapy was 50 years, with a range of 23 to 81 years. There have been 24,239 treatments at home with a total of 84.86 patient-years on NHHD, the longest patient for 66.7 months and the shortest for 1 month. METHODS: Patients dialyzed using the Fresenius 2008H machine, 6 to 10 hr, 5 to 6 nights per week. Treatment parameters included a blood flow rate of 200 to 250 mL/min; a dialysis flow rate of 200 to 300 mL/min; and a standard dialysis solution with 2.0 mEq/L potassium, 3.0 to 3.5 mEq/L calcium concentrations, 35 mEq/L HCO(3), and 140 mEq/L sodium. The longitudinal data of each patient in the program for 1, 2, 3, 4, and 5 years were compared to the same patient's pre-NHHD data. There were 25 patients in the program for 1 year, 19 patients for 2 years, 14 patients for 3 years, 6 patients for 4 years, and 4 patients for 5 years. RESULTS: Statistically significant improvement occurred in all five groups' need for antihypertensive medications and phosphate binders, SF36 scores, calcium/phosphorus product, blood pressure, number of hospital admissions, and number of days of stay in the hospital. The mortality rate was 2.4% deaths per patient-year with a 95% confidence interval of 0.9% to 9.4%. CONCLUSIONS: In a longitudinal study, NHHD showed significant improvements in patient secondary outcomes. The improvement in these secondary outcomes was associated with an improvement in mortality rate.

Nightly Home Hemodialysis: Fifteen Months of Experience in Lynchburg, Virginia.

What constitutes adequate dialysis has been debated in the nephrology literature over the past eight years. The mortality rate of patients on dialysis in the United States is about 20% per year. We believed that short and infrequent dialysis sessions contributed to poor outcomes. To improve the results, Lynchburg Nephrology started the nightly home hemodialysis (NHHD) program in September 1997. Ten patients were trained in the first 15 months of the program. Patients dialyzed 7 - 9 hours, 6 nights/week, using the Fresenius 2008H machine. A standard dialysis solution with 2.0 mEq/L potassium, calcium concentration of 3.0 - 3.5 mEq/L was used. Dialysis solution flow rates were 200 - 300 mL/min. Serum phosphate levels were maintained above 2.5 mg/dL by adding 0 - 45 mL Fleet's Phosphosoda to the bicarbonate bath. Patients had marked improvement in quality of life as measured with the SF-36. Blood pressure was better controlled with fewer medications. All phosphate binders were eliminated. Caloric intake and protein intake increased to normal levels as measured by three-day dietary histories pre-NHHD, and at 3, 6, and 12 months on NHHD. Epoetin alfa dosages were reduced by about 50%. Nightly home hemodialysis should be considered as a valuable modality option for end-stage renal disease patients; it is potentially superior to conventional thrice-weekly hemodialysis.