Nocturnal Home Hemodialysis

Getting 8-hours of HD at a time means that the treatments can be very slow and gentle, and easy on your heart. You'll train during the day but most people do the long treatments at night while they sleep once they go home. Studies show that people sleep better with HD treatments at night than with standard HD. The longer treatments help you to have more-normal levels of a sleep hormone (melatonin). Some people do take some time to get used to sleeping with the machine on. You will have alarms to wake you up if even a drop of blood leaks at night. Knowing that the alarm will protect you can help you relax and sleep.

Research finds that people who do longer HD treatments at home may live about three times as long as those who do standard HD in a clinic.

Most people who do nocturnal home HD dialyze every other day, or 4, 5, or 6 times per week. They don't have a 2-day gap with no blood cleaning.

Nocturnal home HD benefits in brief:

• Flexible – Choose treatment times that fit into your life
• Convenient – Have your days free
• Energy – 2–4 times as much dialysis for more energy, libido, and appetite
• Control – Eat, drink, and have visitors during treatments
• Access – Lasts longest when you put in your own needles
• Gentle – This treatment is very easy on your heart
• Freedom – Eat and drink more of what you like and make fewer trips to the clinic
• Survival – You may live about as long as if you get a deceased donor kidney transplant (3 times better than with standard in-center HD).

Getting ready for nocturnal home HD:

To do any type of HD, you will need a surgeon to make you a vascular access (a way to get blood to the dialyzer).

If you sleep during your nocturnal home HD treatments, you will:

• Learn to tape your needles very well
• Place an alarm that can detect even a drop of blood under your access arm (a bedwetting alarm, or a special alarm made for this purpose)
• Place a second alarm under the dialyzer to detect blood leaks there

These steps can help assure your safety. (In the state of New York, treatments must be monitored remotely, but this has not been shown to be any safer.)

Tip: Learn more in Kidney School Module 8— Vascular Access: A Lifeline for Dialysis .

Training

When your access is ready to 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 24 hours a day, 7 days a week to help you and answer your questions.

Where can you get nocturnal home HD?

Dialysis first started in the U.S. in the late 1960s and early 1970s. Back then, home HD was the most common type of treatment. Long, slow, gentle treatments were the norm! But, in 1973, Medicare started to pay for dialysis. Many clinics began to open and nocturnal home HD faded away. In-center HD treatments are shorter and harder on your body. Today, with more evidence that supports the benefits of longer treatments, this option is making a comeback.

Thanks to demand from people like you, there are more nocturnal home HD options. Some people even move to be closer to a center that will let them do the kind of treatment they want. Of the more than 5,000 dialysis clinics in the U.S., about 8% now train people to do nocturnal home HD. Once you finish training, you only have to go to the clinic once a month. So, you can choose a clinic that is farther away from your home. Nocturnal home HD is offered in every state except South Dakota and Wyoming. Find a center near you.

Time

Nocturnal home HD takes about half an hour each night for set up. The 7–9 hour treatments can be done while you sleep, so this option can give you the most blood cleaning—but take the least time out of your day! You decide when to start and finish the treatments. In the morning, clean up takes another 15 minutes or so. To learn about home HD machines, check out our section on home HD equipment.

Once you're trained, you'll need to go to the clinic once a month to have your labs checked, meet with your care team, 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 make dialysate, depending on the machine you use. Your machine may need repair at times, too.

People who do nocturnal home HD feel well just 10 minutes or so after a treatment. So, this option can give you a lot of your life back.

Space needed

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

Most people use a bed for nocturnal HD, so they can sleep. Since you can lie flat in a bed, your clinic does not have to provide a chair for this option. You may want to use a mattress cover in case of blood leaks. Chux or other absorbent pads can be used under your arm when you put the needles in to keep your sheets clean.

Care partner tasks

Most, but not all, clinics require a care partner for nocturnal home HD. This option is safe enough that some people go it alone, sometimes with a "Life Alert" type of alarm that can call a neighbor or 911. The frequent treatments are gentle, and problems are very rare. So, lack of a partner is not the same concern as it would be with standard HD. A partner should not have to do much 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 putting in the needles. After all, it's your treatment.

Your care partner may fetch things you can't reach when you're hooked up to the machine, and give you medicines or saline. Some care partners move supplies around or even set up the machine.

Most often, a family member or friend trains to be a care partner. Sometimes, people hire nurses or techs to be care partners. Medicare does not pay for home HD care partners. A few clinics pay for them—but this is very rare. In most cases, people who hire a care partner must pay for it themselves. Some pay an hourly fee, others trade free rent in a spare room for help, or even trade helping tasks with someone else on home HD.

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

Nocturnal home HD may be a good choice for you if you want to:

• Feel well all the time. With long, gentle treatments, you'll feel well 10 minutes after a treatment.
• Keep your job. Do your treatments at night while you sleep. Nocturnal home HD is work-friendly.
• Eat and drink more normally. You may have few (or no) limits on fluid, potassium, sodium, and phosphorus.
• Swim or take tub baths. If you have a fistula or graft for access, you can swim and bathe after the needle sites scab over after a treatment.
• Spend more time with your loved ones. You won't need to spend much time at the dialysis clinic, except for monthly visits. And, you may be more likely to think of yourself as mostly healthy.
• Feel in control! Research shows that the more you know about your treatment and do for yourself, the longer you may live. Nocturnal home HD puts you in the driver's seat.
• Avoid painful cramps. Long treatments are so gentle that cramping is extremely rare.
• Protect your nerves, joints, and bones. Long treatments remove far more of the "middle molecules" thought to cause nerve, joint, and bone damage.
• Protect your heart. Blood pressure is much lower with nocturnal home HD than it is with standard HD. It's gentler on your heart.
• Have a healthy sex life. People who get more HD say that their sex lives improve.
• Have a baby. There are not many studies on this. But, women who get at least 20 hours of dialysis a week seem to have a better chance of carrying a baby to term.
• Stay out of the hospital. People who do nocturnal HD are less likely to have hospital stays.
• Live as long as you can. Studies have found that people who do nocturnal HD may live as long as those who get a deceased donor kidney transplant. People who do nocturnal home HD may live 3 times longer than those who do standard in-center HD.

Nocturnal home HD may not be a good choice for you if you want to:

• Spend time with others on dialysis. You'll go to the clinic once a month for a visit with your care team, but may not see others who use nocturnal home HD. You can find them online, though.
• Dialyze by yourself. Most clinics will require you to have a partner.
• Keep dialysis out of your home. Since this is a home treatment, you would need to have a machine and supplies there.
• Avoid needles. All HD requires needles (unless you use a catheter, which is risky).
• Avoid missing work time for training. Most clinics do home HD training during work hours. Some will be willing to try to work with your schedule. For most people, nocturnal home HD training takes 3–4 weeks or longer. Training can be shorter if you learn to put in your own needles before you start. Once you are trained, you are likely to miss less work time than if you did standard HD in a center.
• Travel. You may be able to use a NxStage machine for nocturnal home HD. If so, you can take it along when you travel. But, if you use a standard HD machine, it is not portable. This means that to travel, you need to set up dialysis with a clinic where you'll be going. And, to stay safe, you'll need to adjust your diet and fluid intake for getting much less dialysis.

Who is best suited for nocturnal home HD?

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

Tip: Bringing HD into your home is a bit like bringing home a new baby. There is a machine and supplies to find space for, and new roles for you and your care partner to take on. The "baby" affects your home and your schedule. Planning out who you think will do what is wise—but plans may need to change in real life. Talk with your partner. Be kind to each other. Show appreciation for any help you get from your partner. You are a team, on the same side in all of this.

Try to clear your calendar when you go through training so you can focus. Make meals ahead and freeze them, if you can. When you start to do treatments at home, expect to feel overwhelmed for the first 3 months or so—that's very normal. Hang in there. You'll get into a routine, and the treatments will get much easier. You'll be so proud of yourselves when you succeed!

Thinking about nocturnal home HD? Learn how to choose a home dialysis clinic.