HOME HAEMODIALYSIS

3.0 The Benefits of Frequent Dialysis

Introduction

There are many perceived benefits of Home Haemodialysis (HHD), and many correlate with significant improvements in health outcomes. The benefits may be due to both clinical and psychosocial effects of HHD:

• In the home environment, patients enjoy the very important benefit of increasing the frequency of dialysis treatments and possibly extending the duration of sessions or at least cumulative hours of dialysis per week.
• The patient manages treatment, so adherence improves; the patient experiences increased self-esteem and regains control of his or her health and life.
• Compared to conventional haemodialysis HHD patients experience increase freedom. The time that previously was put into traveling and waiting to receive dialysis treatment at the clinic can now be devoted to socializing with family and friends, as well as spending time on leisure activities and work, particularly if dialysis occurs overnight¹.

However, the patient must consider that HHD is more than a lifestyle choice and that there might be situations in which risks may outweigh benefits. Dialysis is always a balancing act between benefits and risks, and this form of therapy is not for everyone2. In this chapter, we will take you through the benefits. It is important to remember there are also disadvantages to HHD and all patients may not experience all benefits (see “Benefits and Risks” at the end of this chapter).

3.1 Improved health

Patients who undergo HHD instead of conventional haemodialysis have reported significant improvements in their physical health. These improvements can become more evident over time²⁹.

3.1.1 Better control of fluid balance

• Frequent dialysis reduces weight gain between dialysis sessions. Patients report less thirst. Better volume control reduces Left Ventricular Mass (LVM) which is associated with mortality and cardiovascular morbidity^3,4,5.
• With less fluid to remove at each session, ultrafiltration can occur more gradually resulting in less cramping and episodes of hypotension during dialysis¹.
• Blood pressure declines. This is one of the most consistent benefits of HHD in randomized and non-randomized studies alike. A reduction in fluid overload seems to be the main mechanism for blood pressure reduction with HHD^4,5.

3.1.2 Improved blood biochemistry

The kidney has many functions which means that many different biochemical parameters are adversely affected when the kidneys stop functioning. With dialysis, these improve and with frequent dialysis further improvements are seen. “The more you dialyze, the more you clean”⁶.

• Efficient clearance of urea, creatinine, uric acid and Beta-2-microglobulin.
• Increased removal of phosphorus with more hours of haemodialysis per week^4,30.
• Reduction in inflammatory markers³¹.

3.1.3 Improvement in nutritional status

• Reduced need for dietary restrictions^24,25,30.
• Improved appetite^24,25.

3.1.4 Decreased medication burden

Dialysis patients typically take many prescription medications, many of which are very expensive. The improved physical health associated with more frequent HHD is often accompanied with a reduced need for medications.

• Patients have improved blood pressure control and can decrease or even avoid antihypertensive medications^26,30.
• Patients with lower serum phosphorus due to more dialysis may have significantly reduced need for phosphorus binders (especially with nocturnal HD⁷).
• The required dose of erythropoietin may decrease^8,9.

3.1.5 Improved pregnancy outcomes

Pregnancy in women with end stage renal disease on renal replacement therapy is uncommon due to the physiologic changes associated with renal failure as well as the complexities and risk involved in managing these patients. For those able to conceive, intensified haemodialysis (HD), through longer and/or more frequent haemodialysis sessions, offers improved maternal and neonatal outcomes¹⁰.

Nocturnal HD (NHD) has been associated with delivery of infants with higher weights born at more advanced gestational ages, as well as fewer maternal and fetal complications. These encouraging results suggest a greater role for much more intensive dialysis in pregnancy¹¹.

3.1.6 Survival

More frequent HHD is associated with improvements in patient survival, compared to Conventional Haemodialysis (CHD)¹². On average, patients on HHD live four years longer than patients on CHD¹³. Several studies have compared survival on Short-Daily Haemodialysis (SDHD), Home Haemodialysis (HHD), Nocturnal Haemodialysis (NHD), and Conventional Haemodialysis (CHD). In general, the survival results have been higher for SDHD, HHD and NHD^4,12. Recent data, taken mainly from the Frequent Haemodialysis Network (FHN) Daily Trial with 245 patients randomly assigned to either 6 or 3 in-centre haemodialysis sessions per week for 12 months, demonstrates reduced left and right ventricular end systolic and diastolic ventricular volumes as well as reduced left ventricular mass index^5,15.

Other observational studies report

• A reduction in mortality risk equal to 7% for every 30-min increase in dialysis treatment time¹⁶.
• The long-term survival on frequent HHD is good and has improved over time. More frequent HHD may represent a good alternative to a deceased-donor kidney transplant for certain patients1^3,4.

3.2 Enhanced Quality of Life

Most patients with end-stage kidney disease experience several physical, mental, and psychosocial problems that have a major impact on quality of life (QoL). They place enormous value on their Health-Related Quality of Life (HRQoL), more so than even survival, and want to know how their HRQoL will be affected by their choice of dialysis modality¹⁷.

3.2.1 Tools to measure Quality of Life

There are a number of tools that can be used to measure quality of life. In the FHN Daily Trial, results showed higher scores for more frequent versus conventional HD using four tools¹⁸;

• Feeling thermometer – a single question that asks patients to rate their own health on a visual analog scale from 0 to 100, where 0 is dead and 100 is perfect health.
• A general health scale – 5 items from the RAND KDQoL SF-36 questionnaire.
• Time to recover from a dialysis session.
• Health Utilities index (The Health Utilities Index Mark 3) – a commonly used and validated survey in which participants rate their health on the following 8 attributes: vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain.

3.2.2 Recovery Time

One of the most striking changes noted with frequent HD is that recovery time or post dialysis fatigue was reduced and that patients could return to normal daily activities shortly after completion of treatment^17,19.

3.2.3 Improved vitality and energy

Improvements in patient reported vitality and energy have been seen²⁰. There is improvement in sex-related hormones which can improve the quality of sexual relationships²⁷.