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

1. Jaar BG, Plantinga LC, Crews DC, Fink NE, Hebah N, Coresh J, Kliger AS, Powe NR. Timing, causes, predictors, and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study. BMC Nephrol. 2009 Feb 6;10:3.
2. USRDS 1997 Annual Data Report, USRDS Dialysis Morbidity and Mortality (Wave 2), 53.
3. Wuerth DB, Finkelstein SH, Schwetz O, Carey H, Kliger AS, Finkelstein FO. Patients' descriptions of specific factors leading to modality selection of chronic peritoneal dialysis or hemodialysis. Perit Dial Int. 2002 Mar-Apr;22(2):184-90.
4. Noshad H, Sadreddini S, Nezami N, Salekzamani Y, Ardalan MR. Comparison of outcome and quality of life: haemodialysis versus peritoneal dialysis patients. Singapore Med J. 2009 Feb;50(2):185-92.
5. Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A, Finkelstein FO. Hemodialysis and peritoneal dialysis: patients' assessments of their satisfaction with therapy and the impact of the therapy on their lives. Clin J Am Soc Nephrol. 2006 Nov;1(6):1191-6.
6. Weinhandl ED, Foley RN, Gilbertson DT, Arneson TJ, Snyder JJ, Collins AJ. Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010 Mar;21(3):499-506. Epub 2010 Feb 4.
7. Van Biesen W, Dequidt C, Vijt D, Vanholder R, Lamiere N. Analysis of the reasons for transfers between hemodialysis and peritoneal dialysis and their effect on survivals. Adv Perit Dial. 1998;14:90-4.
8. Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule, from CMS. Accessed 3/2010.
9. Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int. 1999 Apr;55(4):1553-9.
10. Okada K, Abe M, Hagi C, Maruyama N, Ito K, Higuchi T, Matsumoto K, Takahashi S. Prolonged protective effect of short daily hemodialsyis against dialysis-induced hypotension. Kidney Blood Press Res. 2005;28(2):68-76.
11. Goldfarb-Rumyantzev AS, Leypoldt JK, Nelson N, Kutner NG, Cheung AK. Crossover study of short daily haemodialysis. Nephrol Dial Transplant. 2006 Jan;21(1):166-75.
12. Fagugli RM, Reboldi G, Quintaliani G, Pasini P, Ciao G, Cicconi B, Pasticci F, Kaufman JM, Buoncristiani U. Short daily hemodialysis: blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients. Am J Kidney Dis. 2001 Aug;38(2):371-6.
13. Heidenheim AP, Leitch R, Kortas C, Lindsay RM. Patient monitoring in the London Daily/Nocturnal Hemodialysis Study. Am J Kidney Dis. 2003 Jul;42(1 suppl):61-5.
14. Blagg CR, Kjellstrand CM, Ting GO, Young BA. Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio. Hemodial Int. 2006 Oct;10(4):371-4.
15. Kjellstrand CM, Buoncristiani U, Ting G, Traeger J, Piccoli GB, Sibai-Galland R, Young BA, Blagg CR. Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years. Nephrol Dial Transplant. 2008 Oct;23(10):3283-9.
16. Geary DF, Piva E, Tyrrell J, Gajaria MJ, Piccone G, Keating LE, Harvey EA. Home nocturnal hemodialysis in children. J Pediatr. 2005 Sep;147(3):383-7.
17. Warady BA, Fischbach M, Geary D, Goldstein SL. Frequent hemodialysis in children. Adv Chronic Kidney Dis. 2007 Jul;14(3):297-303.
18. Nesrallah G, Suri R, Moist L, Kortas C, Lindsay RM. Volume control and blood pressure management in patients undergoing quotidian hemodialysis. Am J Kidney Dis. 2003 Jul;42(1 Suppl):13-7.
19. Wong JH, Pierratos A, Oreopoulos DG, Mohammad R, Benjamin-Wong F, Chan CT. The use of nocturnal home hemodialysis as salvage therapy for patients experiencing peritoneal dialysis failure. Perit Dial Int. 2007 Nov-Dec;27(6):669-74.
20. Fong E, Bargman JM, Chan CT. Cross-sectional comparison of quality of life and illness intrusiveness in patients who are treated with nocturnal home hemodialysis versus peritoneal dialysis. Clin J Am Soc Nephrol. 2007 Nov;2(6):1995-200.
21. Pauly RP, Gill JS, Rose CL, Asad RA, Chery A, Pierratos A, Chan CT. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant. 2009 Sep;24(9):2915-9.
22. Johansen KL, Zhang R, Huang Y, Chen SC, Blagg CR, Goldfarb-Rumyantzev AS, Hoy CD, Lockridge RS Jr, Miller BW, Eggers PW, Kutner NG. Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study. Kidney Int. 2009 Nov;76(9):984-90.
23. Perl J, Lok CE, Chan CT. Central venous catheter outcomes in nocturnal hemodialysis. Kidney Int. 2006 Oct;70(7):1348-54.
24. Dialysis Needle Fear: Easing the Sting, Home Dialysis Central. Accessed 3/2010.
25. Dialysis Needles, Self-Cannulation, and the Buttonhole Technique, Home Dialysis Central. Accessed 3/2010.
26. Copland M, Murphy-Burke D, Levin A, Singh RS, Taylor P, Er L. Implementing a home haemodialysis programme without adversely affecting a peritoneal dialysis programme. Nephrol Dial Transplant. 2009 Aug;24(8):2546-50.

Copyright © 2010 Medical Education Institute, Inc. All rights reserved.

Innovative HeRO® Device

Innovative HeRO® Device Improves

Outcomes, Quality of Life for Kidney Disease Patients 
1,000 patients nationwide have now received the device
from Minnesota-based Hemosphere, Inc.
February 24, 2010 – Eden Prairie, Minn. – One thousand end stage renal disease patients have now benefited from a novel device that provides vital access to their blood for filtering and replacement kidney function and reduces the risk of potentially fatal bacteremia infection.
The HeRO® Vascular Access Device, produced by Hemosphere, Inc., in Eden Prairie, Minn., provides access for hemodialysis similar to a conventional graft. The device is surgically implanted completely under the skin and its innovative design bypasses central venous damage caused by catheters. More than 1,000 patients in over 220 hospitals across the United States have received the device since its commercialization in May 2008.
“Reaching this significant medical milestone demonstrates increasing physician acceptance of the HeRO Vascular Access Device and its positive contribution toward improved quality of life for kidney disease patients,” said Doris Engibous, President and CEO of Hemosphere, Inc. “The strong clinical results, and the subsequent increasing adoption of the device, reinforce that HeRO can provide improved vascular access performance and reduce healthcare costs compared to catheters.”
Before the introduction of HeRO, hemodialysis patients received a tunneled dialysis catheter when the damage to their central venous systems prevented them from supporting a fistula or graft. Catheters have a number of disadvantages, including high rates of life-threatening infection, inadequate dialysis compared to fistulas and grafts, and are widely known to cause damage to the central veins over time.
HeRO has the potential to establish a new standard of vascular access care to reduce long-term catheter use. The device provides a new option that improves a patient’s quality of life by increasing the effectiveness of hemodialysis treatment and reducing a patient’s risk of developing an often-fatal systemic infection.
“The HeRO device allows for better and more efficient dialysis, so many of my patients who have been implanted with HeRO say they feel better and have more energy,” said Dr. Brad Grimsley, vascular access surgeon at Texas Vascular Associates in Dallas, who performed the 1,000th implant. “Because HeRO is implanted under the skin, it has a significantly lower risk of potentially life-threatening infections than a catheter and allows my patients to enjoy daily activities, like showering or swimming, without worrying about exposing their access to germs and bacteria.”
How HeRO Works
The HeRO Vascular Access Device is made up of two pieces that are surgically implanted under the skin. During surgery, a reinforced tube (called the outflow component) is inserted directly into a large vein in the neck. X-ray is used to direct the tube past any blockages that have caused trouble for other access sites. A regular dialysis graft is sewn to an artery, just like a conventional graft. The graft is then joined to the outflow component with a special proprietary connector. Once the system is in place, blood will flow from the artery through the graft and
Internal Use Only: 15-0002, Press Release 1,000th Implant
outflow component into the heart. Unlike a catheter, there is continuous blood flow even when a patient is not receiving dialysis treatment.
“Our customers, including our earliest supporters in the clinical trial, as well as the dialysis care centers and our most recent certified surgical implanters, are the key to our success. Without their belief and support, HeRO would not be the solution for access challenged patients,” said Engibous. “We are committed to collaborating with clinicians and other members of the dialysis care continuum to improve clinical outcomes for patients for years to come.”
About Hemosphere, Inc. Hemosphere, Inc., is leading innovation and collaboration in the global development and commercialization of technologies that revolutionize care and restore quality of life for end-stage renal disease patients with compromised vasculature.
For more information on Hemosphere, Inc and the HeRO® Vascular Access Device, visit the company’s Web site at www.heroaccess.com.