If PD Fails, Think About Home HD
Some people do peritoneal dialysis (PD) and feel great for 10 or 15 or 20 years. But many who choose PD stop after just 2–3 years. 1 The peritoneum can fail. Or they may have "buyer's remorse" if PD does not fit their lives the way they hoped it would.
If this happens to you and you don't have a kidney transplant donor, 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 look.
Standard in-center HD (three times a week for 3–4 hours) is the "default" treatment. Some end up with it and don't know there are other options. 2 But PD is always a conscious choice. A study of why people choose PD found these reasons: 3
- Flexible schedule
- Convenience of being home
- Option of nighttime treatments
Quotes from people who do PD bear out these key points:
"[In-center] HD 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] HD. 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 Those on PD had a much better quality of life in terms of:
- Social function
- Major depression
And, on a scale of 1-10 (10 was the best), people on PD had a satisfaction rating 8.02. Those on standard in-center HD rated theirs at 7.25—significantly lower. 5 Why choose a treatment that people are less satisfied with?
Survival on PD vs. in-center HD
A look at nine large studies of survival with PD vs. standard in-center HD found that they tend to be about the same. Younger people and those who do not have diabetes tend to live longer with PD than with standard HD. 6
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 requires clinics to tell you about ALL of the treatments for kidney failure—and where you can get them. 8 But we suspect this is not yet done across the US. If you need to make a change, learn your options. You'll be better able to choose a treatment that will fit your life:
- Standard home HD
A nurse trains you and a partner to do HD treatments on a standard HD machine at home 3x/week.
- You will have ups and downs in how you feel, and may not feel well for a few hours after each treatment.
- Just 3 treatments means more fluid and diet limits and meds to take.
- With only 3 treatments, you have a much higher risk of sudden cardiac death on the day after the 2-day no-treatment weekend. 9
- You can schedule treatments when you want, though, and be at home.
- Short daily home HD
A nurse trains you and a partner to use a small machine (see below) to do 2.5–4 hour treatments 5–6 days a week.
- You won't have ups and downs, 10,11
- Eat and drink more of what you like.
- You won't need as many blood pressure pills 12 or binders.
- You may feel well half an hour or so after each treatment. 13
- Survival is much better than standard HD or PD—in fact, it's about the same as deceased donor transplant! 14,15
- Extended home HD
HD treatments are done for 6–8 hours, most often at night while you sleep, 3–6 times/week. This option (which may be called "nocturnal") is closest to PD in terms of lifestyle.
- Slow, gentle treatments are easy on the heart.
- No special diet or fluid limits may be needed. 16,17
- Extended HD removes much more phosphorus so you won't need binders. 18
- Blood pressure pills can be stopped. 19
- People who do extended HD say it is no more of a burden than PD was. 20
- People feel well just 10 minutes after the long treatments. 13
- Studies find that people live about as long as if they had a deceased donor transplant. 21,22
Home HD: Things to Think About
If you switch from PD to HD, there will be needles. Some programs will let you do home HD with a catheter. HD catheters at home are safer than in-center. 23 Learning 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.
- Dialysis Needle Fear: Easing the Sting 24
- Dialysis Needles, Self-Cannulation, and the Buttonhole Technique 25
If you have to have needles for HD, you might as well reap the benefits of better treatment!
Needing a Partner
Most programs require a partner for home HD. It’s best to do as much of your treatment as you can—whether or not you have a partner. If you live alone:
- See if a family member, friend, or neighbor could help you.
- Check your health plan. Medicare will not pay for a home partner, but other insurance might.
- Trade free or low cost rent in a spare room for help with your treatments.
- Seek out programs that do not require a partner.
- Offer to sign a legal release so the clinic can't be sued if you have a problem.
- Look for in-center nocturnal treatments (3x/week) in your town. You get 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 database on Home Dialysis Central to search by type of treatment and zip code.
Both PD and home HD have been growing. 26 There are more than 5,000 dialysis clinics in the US. About 45% have some type of PD. Growth has been much higher in home HD, but only about 15% of clinics offer some type of home HD.
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.
- 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
- USRDS 1997 Annual Data Report, USRDS Dialysis Morbidity and Mortality (Wave 2), p. 53
- 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
- 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
- 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
- Vonesh EF, Snyder JJ, Foley RN, Collins AJ. Mortality studies comparing peritoneal dialysis and hemodialysis: what do they tell us? Kidney Int Suppl. 2006 Nov;(103):S3-11
- 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
- Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int. 1999 Apr;55(4):1553-9
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- Warady BA, Fischbach M, Geary D, Goldstein SL. Frequent hemodialysis in children. Adv Chronic Kidney Dis. 2007 Jul;14(3):297-303
- 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
- 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
- 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
- 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
- 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
- Perl J, Lok CE, Chan CT. Central venous catheter outcomes in nocturnal hemodialysis. Kidney Int. 2006 Oct;70(7):1348-54.
- Dialysis Needle Fear
- 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