If PD fails: Think about home HD

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Some people happily do peritoneal dialysis (PD) for 10, or 15, or even 20, years. But many who choose PD stop after just 2–3 years.¹ The peritoneum may fail, or they may have "buyer's remorse" if PD doesn't fit their lives the way they hoped it would.

If this happens to you and you don't have a kidney transplant donor lined up, you'll need to switch to a form of hemodialysis (HD). Why not home HD?    

Quality of life on PD vs. HD

When making a switch from PD to HD, it makes sense to think about how your quality of life will be affected.
Standard in-center HD three times a week for 3–4 hours can be a "default" treatment. People may end up with it and not even know that there are other options.² But PD is always done as a conscious choice. A study of why people choose PD in the first place found these reasons:³

• Flexible schedule
• Convenience of being home
• Option of nighttime treatments

Statements from people who do PD bear out these key points:

"[In-center] hemodialysis wore me out, to where I couldn't do much other than go to treatments and sleep. Then I found PD, which no one had ever talked with me about before—and after a little research, I made the switch. It was the BEST choice I ever made. I now use a cycler at night, and work during the day."

"I had a terrible time on [in-center] hemo. I was scared at first because I wasn't sure if I could be in charge of my own care. But the difference is night and day for me. I have taken charge, and not only do I feel better physically but emotionally and spiritually too."

"Personally, I prefer PD to even the thought of HD. PD does not interfere with my lifestyle as much as HD would. I am very busy and tell people that I do not have time to sit on a machine for 4–5 hours 3 days a week. I do PD at night on a cycler and am dry during the day so can forget about dialysis during the day. I am able to continue all my activities and work. If I were on [in-center] HD I would have to quit work and would be unable to be as active as I am."

One study looked at quality of life in 60 people on PD and 60 on HD.⁴ It found that those on PD had a much better quality of life in the areas of:

• Stress
• Sleep
• Social function
• Major depression

And, on a scale of 1-10 (with 10 being high), people on PD rated their overall satisfaction at 8.02. Those on standard in-center HD rated theirs at 7.25—significantly lower.⁵ Why choose a treatment with which people are less satisfied?

Survival on PD vs. in-center HD 

A new study matched 6,337 pairs of people who started PD or standard in-center HD in 2003. It found much better survival on PD than on HD.⁶ This was even more true for those under age 65, those who did not have heart disease, and those who did not have diabetes.
While those on PD don't seem to fare any worse after switching to in-center HD,⁷ why not aim for better?

Types of home HD

Medicare rules as of 2008 require people with kidney failure to be told about all of their treatment options—and where to get them.⁸ But we suspect that this is not yet happening everywhere. If PD is no longer working for you, and you need to make a switch, knowing your home options can help you choose a treatment that will fit your life:   

   small home hemo machine

1. Conventional home HD (CHD) – This treatment is done 3x/week. A huge plus of PD is getting treatment all or nearly all the time, so you don't have "ups and downs." CHD 3x/week will give you ups and downs. Just 3 treatments also means more fluid and diet limits and meds to take. And, just 3 treatments raises your risk of sudden cardiac death on the day after the 2-day no-treatment weekend by 50%.⁹ You can schedule treatments when you want, though, and be at home.
2. Short daily home HD (SDHD) – A small machine (about the size of a microwave – see below) is used to do 2–3 hour treatments 5–6 days a week. You won't have ups and downs,^10,11 can have a more normal diet and fluids, and won't need as many blood pressure pills¹² or binders. While it can take as long as 6.67 hours to feel well again after standard HD, those on SDHD felt well in 30 minutes or less.¹³ Studies find that survival on SDHD is much better than standard HD or PD—in fact, it's about the same as deceased donor transplant!^14,15   
3. Nocturnal home HD (NHHD) – HD treatments are done for 6–8 hours at night while you sleep, 3–6 times/week. Slow, gentle treatments are easy on the heart—and clean the blood so well that no special diet or fluid limits may be needed,^16,17 and blood pressure pills can be stopped.¹⁸ People feel well about 10 minutes after NHHD treatments.¹³
   
   Most who do PD use a cycler at night. NHHD is the closest to this, in terms of lifestyle. People who switched from PD to NHHD had higher levels of protein in their blood, higher hemoglobin levels (with less EPO). They had lower levels of phosphorus—even though they didn't need binders.¹⁹ NHHD was not any more of a burden than PD. Finally, like SDHD, studies have found that survival on NHHD is about the same as deceased donor transplant.^21,22

Barriers to home HD

Dialysis needles. The most obvious barrier in switching from PD to home HD are the dialysis needles. Some programs permit home HD using a catheter. HD catheters at home are safer than in-center.²³ Learning how to put in your own needles if you have a fistula or graft puts control in YOUR hands and removes a lot of the pain and fear. You can read about how to do this in our articles:

• Dialysis Needle Fear: Easing the Sting²⁴
• Dialysis Needles, Self-Cannulation, and the Buttonhole Technique²⁵

If you are going to have to have needles anyway for HD, you might as well get the benefits of longer and/or more frequent home treatment!
Needing a partner. Many programs require a partner for home HD. If you don't have one, look for programs that do not require this. Or, see if you can do in-center nocturnal treatments (3x/week) in your town. This gives you most of the pluses of home treatment with no need for a partner.

Finding a home HD program. Not knowing where to find home HD can also stop you. Look at the "Find a Clinic Near You" database on Home Dialysis Central to search by type of treatment and zip code.

Both PD and home HD have been growing. We have kept track of the numbers of home programs since we started Home Dialysis Central in 2004, and this is what we've seen: 

Treatment	'04	'09	% Growth
CAPD	1460	2143	46.7
CCPD	1428	2126	48.9
3x week HHD	294	765	160.2
Daily HHD	37	537	1351.3
Nocturnal HHD	73	274	275.3

There are about 5,000 U.S. dialysis clinics. In 2004, about 30% had some type of PD. Today, about 45% do. Growth has been much higher in home HD, but only about 15% of clinics offer some type of home HD.

Conclusion

You may or may not want to switch from PD to some form of HD. But if you need to for some reason, it's good to know that there are home HD treatment options that can help you keep the freedom, flexibility, and control of PD.

References

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2. USRDS 1997 Annual Data Report, USRDS Dialysis Morbidity and Mortality (Wave 2), 53.
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