Nocturnal home HD benefits in brief:

• Convenient - have your days free
• Quality - get 2–5 times as much dialysis
• Gentle - easy on your heart
• Feel better - more energy, libido, and appetite
• Less restrictive - easier diet, fewer drugs
• Time - fewer trips to the clinic
• Longer life - survival may be about the same as deceased donor transplant (3 times better than standard in-center HD).

How nocturnal home HD works

HD pumps your blood through a machine with a special filter to remove wastes and excess water. The filter is called a dialyzer. It is a plastic tube filled with hollow fibers. A needle connects to a tube that takes your blood to the dialyzer. A second needle connects to a tube that brings your blood back to you. Each time your blood goes through the dialyzer, it gets a little bit cleaner. The machine pushes your blood through the dialyzer and keeps track of time, temperature, blood flow speed, and pressure.

For nocturnal home HD, you and a partner train for a few weeks and learn to do your treatments at home, 3–6 nights a week. You start the treatment, go to sleep, and get off of the machine in the morning when you wake up. Your blood moves through the dialyzer very slowly. This gives wastes and fluid much more time to move into your bloodstream where they can be removed. Nocturnal home HD removes more water and wastes than any other type of dialysis. More dialysis is better.

In-center nocturnal HD

Some clinics now offer in-center nocturnal HD. This is most often done 3 nights a week, from about 8pm to about 4am. While in-center nocturnal is not a “home” treatment, it is much better dialysis than standard in-center treatment. It may be a good option if you don’t have a partner or can’t have a machine in your home. With twice as much treatment, you can feel better and studies show that you may live longer, too. Find a center near you.

See how dialysis works. Reused with permission from Kidney School™.

Preparing for nocturnal home HD: Vascular access

To do any type of HD, you need a way to get blood to the dialyzer. This is done by using one of three types of vascular access:

• Fistula - for this “gold standard”, a surgeon links an artery and vein, most often in your arm. A fistula is all your own tissue, and is under your skin. This makes it far less likely to get blood clots or infection than any other access. A well cared for fistula can last for years—even decades. The best chance for a long fistula life is if you (or a partner) are the only ones who put needles in it.
• Graft - A graft links an artery and vein with a piece of man-made vein. Grafts are more likely than fistulas to get infections and blood clots. They often need “tune-ups” to declot or replace them. Grafts may last up to a few years.
• Catheter - A plastic tube can be placed into a central vein in the neck or chest. Catheters can let germs into your body that can cause sepsis (blood poisoning). Sepsis is a frequent cause of death in people on dialysis. It is best to avoid HD catheters as much as you can.

You are asleep during nocturnal home HD treatments, so your needles must be taped very well. Placing one alarm that can detect even a drop of blood under your access arm, and one under the dialyzer, can help assure safety. (In New York state, treatments must be monitored remotely, but this has not been shown to be any safer.)

TIP: You can learn more about vascular accesses and how to care for them in Kidney School Module 8 - Vascular Access: A Lifeline for Dialysis, at Kidney School™.

Training

After your access is ready for use, you’ll have a few weeks of training. Your training nurse will teach you and your partner how to:

• Set up a treatment room
• Take care of your access and put in the needles
• Figure out how much fluid to remove
• Run and care for the dialysis machine
• Store and order your supplies
• Keep treatment logs
• Take your blood pressure
• Follow your diet and fluid limits
• Recognize and report any problems

Often, your first treatments at home will be during the day. A nurse may come to your home to watch you and be sure that you feel confident. Once you are home, a nurse will be on call if you need help.

Availability

In the late 1960s and early 1970s when dialysis first started in the U.S., home HD was the most common type of treatment—and long, slow, gentle treatments were the norm! But once many dialysis clinics began to open, home HD faded away. In-center dialysis treatments are usually shorter and harder on your body. Now, with new, easy-to-use machines on the market (and more improvements on the way), slow nocturnal home HD is making a comeback.

Thanks to demand from people like you, there are more nocturnal home HD options every day. Some people even move to be closer to a center that will let them do the kind of treatment they want. Of the 5,600 dialysis clinics in the U.S., about 1 in 10 now train people to do nocturnal home HD. Nocturnal home HD is offered in 48 of the 50 states. Find a center near you.

Cost

In the U.S., a large part of the cost of HD is paid for by the Medicare ESRD Program. Most Americans (93%) qualify for these Medicare benefits, no matter how old they are. But, Medicare only routinely pays for 3 treatments per week—not 4 or 5 or 6. Your doctor must write you a letter of medical justification to get Medicare to pay for a 4th treatment (the most Medicare will cover). A health plan may or may not pay for more than 3 treatments per week.

Cost for you: Do you have a job with a health plan? If you do, your health plan will pay first for your first 30 months of treatment. Medicare, if you choose it, will be secondary. That means it will pay some or all of the balance left over after your health plan pays (if the charge is something Medicare pays for).

When you don’t have a health plan through an employer, home HD can really help you. Why? Most people under age 65 can’t get Medicare until the 1st day of their 3rd month of treatment. Those 3 months of treatment can cost tens of thousands of dollars. Some people go bankrupt. But if you do home HD, Medicare will start to pay on day 1.

Your water and electricity bills will go up a bit, but you won’t have to pay for gas to drive to and from a clinic 3 times a week.

As hard as it can be, read your health insurance policy. Some health plans will not pay for more frequent HD at home. This may limit you to three treatments per week or every other night. You can avoid plans like these if you read the fine print. Talk to your dialysis clinic—they may know which plans are best for the type of treatment you want to do.

TIP: Life Options offers a free 108-page booklet called A Kidney Patient’s Guide to Working and Paying for Treatment. Download it here.

Cost for your clinic: Medicare pays for dialysis with a set fee per treatment, called a bundled payment. If you only have Medicare and want to do nocturnal home HD, you may be limited to 3 treatments per week, or every other night. If you want to do nocturnal treatments more often, your doctor may be able to write a letter of medical justification for a 4th treatment (the most Medicare will cover). Clinics do best if people who want to do nocturnal HD more than 3 times a week have an employer group health plan (EGHP). EGHPs may pay many times what Medicare will for a treatment, and they may pay for more than 3 treatments.

Because the clinic must use a machine just for you with nocturnal home HD and must take the time to train you, you will need to show a real commitment for them to say yes.

Time

Nocturnal home hemodialysis takes about 7–9 hours each night that treatment is done—but since you are asleep, it takes very little time out of your day. You decide when to start and finish the treatments.

It takes time to set up the machine for each run and to clean it afterward. How much time this will take depends on the machine. To learn about HHD machines, check out our section on home hemo equipment.

Once you’re trained, you’ll need to return to the clinic once a month to have your labs checked and go over your treatment logs. You’ll also need time to check your supply levels, order supplies each month, and receive the shipment. You may also need to prepare dialysate, depending on the machine you use. Your machine may need repair sometimes, too.

Even with the time it takes to do nocturnal home HD, you may gain time if you do it. Why? Because with standard in-center HD, you may feel washed out, weak, or tired for as long as 7 hours after each treatment. But people who do nocturnal home HD feel well just 10 minutes or so after a treatment. So, it can give you a lot of your life back.

Space needed

You will need a place for a chair and machine. You’ll also need space to store dialyzers, bottles of dialysate, bleach and disinfectant, syringes, needles, medications, blood tubes, water test kits, etc.—depending on the machine.

Helper tasks

Most—but not all—clinics require a helper for nocturnal home HD. Some people do their treatments alone, sometimes with a “life alert” type of personal alarm that can call 911. Since the longer treatments are more gentle and problems are very rare, the lack of a partner has not been as great a concern. It also means that a partner should not have to take on much of the work if you are in good health apart from kidney failure. It’s best if you do as much of your own treatment as you can—especially placing the needles. It’s your treatment.

Your dialysis helper may place one or both of your needles, fetch things you can’t reach when you’re hooked up to the machine, give you medications or saline, or be ready to call 911.

Most often, a family member or friend trains to be a helper. Sometimes people hire dialysis nurses or techs to be helpers. Medicare does not pay for home HD helpers. A few clinics pay for them—but this is very rare. In most cases people who hire a dialysis helper have to pay themselves. Some pay an hourly fee per hour, others offer free rent in a spare room in exchange for help, or even trade helping tasks with another person on home HD.

If you work, you may be able to write off the cost of a helper as a medical deduction on your taxes. If you work and get Social Security disability income, home helper payments may count as an “impairment-related work expense.” This lets you earn more and still keep a disability check.

Nocturnal home HD pluses

• You can dialyze at night and keep your days free. Nocturnal home HD is a work-friendly treatment.
• With 24 to 60 hours of blood cleaning—instead of about 14 hours with standard in-center HD—people sleep and eat better, and have better libido and more energy.
• The slow, gentle treatment is easier on your heart, and is less likely to cause cramping and ups-and-downs than standard in-center HD.
• The diet and fluids may be near-normal with more treatment.
• You will need fewer drugs, or lower doses of some drugs. Some people need phosphate supplements instead of binders.
• When you (or a partner) are the only ones putting needles in your access, a fistula (if you use one) is likely to last longer with fewer problems or trips to the hospital.
• You’ll save time not having to travel to and from the clinic three times a week.
• Nocturnal home HD controls blood pressure very well, which can help protect your heart from damage.
• Studies have found that people who do nocturnal home HD may live about as long as those who get a kidney transplant from a deceased donor. This is about three times longer than standard in-center HD.
• Research shows that the more you know about your treatment and the more you do for yourself, the longer you are likely to live.

Nocturnal Home HD Minuses

• Needing a partner to be there for each treatment can strain your relationship, or cost you money to hire someone. (NOTE: Strong relationships tend to get stronger with home HD.)
• Training can take a few weeks, and you may need to take time off work to do it.
• You and a partner will need to learn to keep your cool and deal with problems that may arise.
• If you use a fistula for access, two needle sticks are needed for each treatment, and you or your partner will need to learn to place them. (You can use a cream to numb the sites so it doesn’t hurt.)
• If you dialyze with a catheter, you’ll need to take care to avoid infection, and your activities (swimming, etc.) may be limited.
• Machine alarms or noises may disturb your sleep.
• It can be hard on you to travel and get in-center HD when you are used to more frequent treatments. You can look for in-center nocturnal, or take your machine with you (if it’s small) when you travel.

Who is best suited for nocturnal home HD?

The most important factor in whether you are suited for nocturnal home HD is how much you want to do it. As long as you or a partner can pass the training and learn to place your needles, you should be able to succeed. Each program that offers nocturnal home HD has its own screening methods to be sure that people understand what they are getting into and are willing to commit to the training and the treatment.

Interested? Learn about how to choose a home dialysis clinic.