Clinical Advantages of Home Hemodialysis

Home hemodialysis (HHD) has emerged as an important alternative treatment option for patients with end stage renal disease. The renaissance of HHD is based in part on several established and potential clinical benefits. In addition, HHD also acts as a conduit for intensive hemodialysis, which is otherwise not feasible in the context of dialysis centers. Various considerations and implications of establishing and implementing HHD have already been covered in this issue of ASN Kidney News. The clinical benefits of HHD will be discussed and summarized here.

In the past decade, there has been a substantial increase in both observational and randomized controlled data in the domain of HHD. Of note, survival advantage has been documented in cohorts of short daily hemodialysis and nocturnal hemodialysis. Overall, the survival rates of daily hemodialysis patients are in the range of 90 percent, 70 percent, and 50 percent at 1, 3, and 8 years, respectively. Similarly, the 1-, 3-, and 5-year survival rates for nocturnal hemodialysis are in the range of 95 percent, 90 percent, and 85 percent, respectively. Given that there is a specific selection bias in patients conducting intensive hemodialysis, investigators have also used kidney transplant recipients as a potential control group. Recently, Canadian nocturnal home hemodialysis patients were compared with a Canadian kidney transplant cohort (1). The kidney transplant patients had a 55 percent to 61 percent (depending on organ donor type) reduced risk of treatment failure or death during the study compared with patients using long and frequent HHD. The risk of being admitted to the hospital and spending a longer time in the hospital was higher for some kidney transplant patients for as long as a year after transplantation, but it was lower in the long term compared with dialysis patients.

HHD has also been documented to have improvements in blood pressure regulation, regression of left ventricular hypertrophy, restoration of left ventricular ejection fraction, normalization of phosphate control, and certain aspects of quality of life related to kidney disease. Other measurements of dialysis intrusiveness, such as recovery time from dialysis treatments, clearly favor HHD over in-center thrice-weekly hemodialysis. Moreover, quality of sleep and sleep apnea have also been improved, especially in the case of nocturnal home hemodialysis. Finally, as an attempt to restore the “unphysiology” of dialysis, HHD has been shown to improve endothelial progenitor cells and diminish the extent of myocardial stunning.

End stage renal disease has traditionally been associated with a low conception rate and poor pregnancy outcomes. Longer weekly dialysis times and lower urea levels throughout pregnancy have been suggested to be protective. In a comparative analysis, conception rate, gestational age, and proportion of live birth were significantly higher in a cohort of nocturnal HHD patients than in a contemporary North American control group.

HHD has several important clinical advantages. It is, however, important to acknowledge that potential risks exist with any form of renal replacement therapy. In the case of HHD, further work is required to minimize potential adverse events (for example, vascular access infection or malfunction) and to improve patient-, facility-, and physician-level barriers. There is a growing appreciation for intensive HHD as an accepted first-line renal replacement therapy. Our community should be charged with enthusiasm to engage with all stakeholders to focus on optimizing the delivery of HHD.

Reference

1

Tennankore KK, et al.Survival and hospitalization for intensive home hemodialysis compared with kidney transplantation. J Am Soc Nephrol. doi:10.1681/ASN.2013111180.