EDUCATIONAL REVIEW

Home haemodialysis

Daljit K. Hothi & Lynsey Stronach & Elizabeth Harvey

Received: 3 June 2012 /Revised: 12 August 2012 /Accepted: 13 August 2012 /Published online: 3 November 2012# IPNA 2012

Abstract Haemodialysis (HD) began as an intensive caretreatment offered to a very select number of patients in anattempt to keep them alive. Outcomes were extremely poor,and the procedure was cumbersome and labor intensive.With increasing expertise and advances in dialysis equip-ment, HD is now recognised as a life-sustaining treatmentthat is considered a standard of care for children with endstage renal disease (ESRD). Assessment of efficacy hasevolved from mere survival, through achieving minimalstandards of “adequate” dialysis with reduced morbidity,towards the provision of “optimal dialysis”, which includesattempts to more closely mimic normal renal function, andof individualised care that maximizes the patient’s health,psychosocial well-being and life potential. There is arenewed interest in dialysis, and the research profilehas extended, exploring themes around convective ver-sus diffusive treatments, HD time versus frequency andhome versus in-centre dialysis. The results thus far haveled dialysis care full circle from prolonged, home-basedtherapies to shorter, intense in-centre dialysis back tothe belief that long or frequent HD at home achievesthe best outcomes.

Keywords Home . Haemodialysis . Pediatric . Quotidian

Introduction

In 1854 Thomas Graham of Glasgow first presented the prin-ciples of solute transport across a semi-permeable membrane[1], but it was not until 1914 that Abel et al. developed andtested the first efficient dialysis system at Johns Hopkins Uni-versity School of Medicine [2]. The first human haemodialysis(HD) was performed in a uraemic patient by Haas in 1924 atthe University of Giessen in Germany [3], but the first toconstruct a working dialyser was Dr. Willem Kolff in the1940s [4]. In 1945 he successfully treated a 67-year-old womanin uraemic coma who regained consciousness after 11 h of HDwith Kolff’s dialyser. The original Kolff kidney was not veryuseful clinically, because it did not allow for removal of excessfluid. Dr. Nils Alwall’s modification of a canister-encloseddialyser led to the application of negative pressure across themembrane, offering the first truly practical application of HD in1946. Alwall was also the inventor of the arteriovenous (AV)shunt for dialysis, describing glass shunts in rabbits in 1948.However, it was Dr. Belding H. Scribner who, working with asurgeon, Dr. Wayne Quinton, truly revolutionised access carewith the formation of the Teflon Quinton–Scribner shunt [5].

Home HD started in the early 1960s, internationally, withgroups in Boston, London, Seattle and Hokkaidō, with pre-scriptions not dissimilar to those of in-centre treatments. In1962, Scribner started the world’s first outpatient dialysisfacility, the Seattle Artificial Kidney Center, later renamedthe Northwest Kidney Centers. As the news of dialysis suc-cess stories spread, demand very quickly exceeded capacity.As a result, difficult decisions about patient selection werebeing made in parallel with discussions surrounding the prac-tical aspects of prolonged dialysis sessions. This was thegenesis of the era of in-centre, intensive 4-h, three-times-per-week, ‘conventional’ dialysis prescriptions with a consensusdefining ‘adequate’ dialysis through blood urea purification,namely Kt/Vurea.

D. K. Hothi (*) : L. StronachNephrology Department, Great Ormond Street Hospitalfor Children Foundation Trust,Great Ormond Street,London WC1N 3JH, UKe-mail: Daljit.Hothi@gosh.nhs.uk

E. HarveyDivision of Nephrology, Hospital for Sick Children,University of Toronto,Toronto, Canada

Pediatr Nephrol (2013) 28:721–730DOI 10.1007/s00467-012-2322-6

Home HD (HHD) was first introduced in the UK [6] andgrew in popularity with the majority of patients being dia-lysed at home, but in the 1970s and 1980s there was a largedecline in home HD. This is thought to be due to a combi-nation of factors, including increased availability of facility-based dialysis, the development of peritoneal dialysis (PD)and the growing success of transplantation. However, in thelate 1990s there was a renewed interest in HHD internation-ally. In the UK, after extensive reviews of the evidence onclinical outcomes and a health economic analysis, in 2002the National Institute for Clinical Excellence (NICE) rec-ommended that home HD should be an option made avail-able to all dialysis patients. For individuals this was aproactive decision around positive lifestyle changes com-bined with emerging evidence highlighting the benefits ofmore frequent and longer dialysis treatments. Finally overthe past decade, there has been a growing consensus ofopinion recognizing intensified HD regimens, set either inhospital or at home, as a viable, safe and beneficial thera-peutic option in children [7].

Dialysis dose

The United States Renal Data System (USRDS) Registryindicated that between 1978 and 1999 the overall 10-yearsurvival rate of adolescents with end stage renal disease(ESRD) was 79.9 % [8]. We now know that the lifespanof a child on dialysis is 40–60 years less than that ofthe general population, while that of a pediatric trans-plant recipient is 20–30 years less than that of thegeneral population [9]. There is no doubt that the needfor dialysis as well as the dialysis procedure itself andpotentially the dialysis regimen are significant risk factorsfor mortality and morbidity in children and adults alike.

Adult studies have demonstrated that dialysis outcomesare determined by a number of factors related to the dialysisprescription and dose. In the HEMO study comparing high-dose HD [urea-reduction ratio (URR) of 75.2 %, single pool

Kt/V (spKt/V) of 1.71, equilibrated Kt/V (eKt/V) of 1.53]against standard dose HD (URR of 66 %, sp Kt/V of 1.32,eKt/V of 1.16), the relative risk of death was 0.96 [10]. In asecondary analysis that looked specifically at women onHD, dose was found to be important, with high dose dialysislowering the risk of mortality. Wolfe et al. [11] corroboratedthese findings, reporting an association with body massindex (BMI), dialysis dose and mortality. Patients treatedwith a URR of >75 % had a statistically lower RR thanpatients treated with a URR of 70–75 % for medium andsmall BMI groups [11]. Daugirdas et al. found that bynormalizing Kt/V to body surface area, most children under10 years of age would receive markedly less dialysis thanadolescent patients despite acceptable eKt/V and std Kt/Vvalues [12]. Theoretically, it is tempting to postulate thatthere may be a survival advantage in increasing the HD dosein women and patients with a low BMI, such as children.

The Dialysis Outcomes and Practice Patterns Study(DOPPS) review of 22,000 adult HD patients from sevencountries found that a higher dialysis dose, as reflected by ahigher Kt/V, was important and an independent predictor oflower mortality on HD with a synergistic survival advantagewith treatment time. Therefore, survival was most pro-nounced by combining a higher Kt/V with a longer treat-ment time, as shown in Fig. 1. Furthermore, these authorsshowed that for every 30 min longer on HD, the relative riskof mortality was reduced by 7 % [13]. The Australian andNew Zealand Dialysis and Transplant Registry (ANZDATA)analysis of 4,193 patients [14] found that the optimal dialysisdose for survival was a Kt/V of ≥1.3 and a dialysis sessionof ≥4.5 h. Dialysis treatments of <3.5 h were associated with ahigher mortality risk [14].

Such research set the scene for ‘Quotidian Dialysis’ pro-grammes, namely a move away from conventional 4-h,three-times-per-week dialysis to more frequent and/or moreprolonged dialysis sessions. The preferred requirement for agreater time on dialysis, coupled with a demand for in-centre HD beds exceeding capacity fuelled the resurgenceof home HD.

Fig. 1 Relationship betweenKt/V, treatment time andrelative risk of mortality [13](used with permission). RRReduction ratio

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Adult home HD experience

With the emergence of an increasing number of alternativedialysis prescriptions, dialysis research has thrived. Currently,the ultimate prize is determining whether time, frequency orconvective therapy offers the greatest health and psychosocialbenefits. For years many researchers have reported on single-centre experiences, but now longitudinal comparative cohortstudies are being organised, structured into multi-centre, in-ternational randomised studies. In addition, an internationalquotidian dialysis registry now offers opportunities both forbenchmarking dialysis practices and describing importanttrends that will inform future research themes and questions.

The literature on dialysis practices is clear and consistent.Compared with conventional dialysis, increasing frequency,time or convective clearance is beneficial to the patient.Ting et al demonstrated 33% survival at 6 years for thoseswitching to short daily HD combined with reduced hospi-tilisation [15]. The authors of a systematic review of shortdaily HD concluded that it was more effective than conven-tional dialysis [16]. Patients on daily HD had fewer vascularaccess problems, better control of hypertension and reducedantihypertensive medication burden, better quality of life,lower incidence of left ventricular hypertrophy, lower con-sumption of recombinant erythropoietin due to the bettercontrol of anaemia and a reduction in the use of phosphatebinders as a consequence of the improved phosphorousclearance [16]. Likewise, in a comparison of six times-per-week HD versus three-times-per-week HD, the FrequentHaemodialysis Network demonstrated improved self-reported physical health and functioning but disappointingly

were unable to corroborate these subjective assessmentswith significant differences in objective physical perfor-mance metrics [17]. There also remains a concern that morefrequent dialysis may also be associated with higher vascu-lar access complications [18].

Nocturnal HD offers greater promise as preliminary adultdata demonstrate its superiority over all other quotidian dial-ysis regimens. Nocturnal HD is associated with a significantreduction in the risk for mortality or major morbid eventswhen compared to conventional HD [19]. In fact, during amatched cohort study comparing survival between nocturnalHD and deceased and living donor kidney transplantation,there was no difference in the adjusted survival betweennocturnal HD and deceased donor renal transplantation, withthe proportion of deaths among the three being 14.7 % fornocturnal HD, 14.3 % for deceased donor transplantation and8.5 % for live donor transplantation [20]. For the first time wemay be able to start believing that HD has a standing equal totransplantation as a renal replacement therapy (see Fig. 2).This is very reassuring for patients who are not eligible fortransplantation or those waiting for a transplant.

Nocturnal HD has also been reported to lower cardiovas-cular morbidity with improved blood pressure (BP) control,reduced antihypertensive burden [21], and significant im-provement in left ventricular mass [22] with attenuateddialysis-induced myocardial dysfunction [23]. Anaemia man-agement is improved associated with enhanced erythropoi-etin responsiveness [24]. Results on uraemic mineral andbone disorder demonstrate improved phosphate and calci-um control associated with a reduced rate of coronarycalcification progression [24]. Concerns over frequent

Fig. 2 Time to death in patientstreated with nocturnalhaemodialysis (NHD) anddeceased (DTX) and livingdonor kidney (LTX)transplantation [20] (used withpermission)

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fistula needling or accessing of central lines by patientshave been dismissed by studies showing superior centralvenous catheter survival in home nocturnal HD com-pared with conventional HD, with higher adverse termi-nal catheter events in the latter [25]. Finally, homenocturnal HD patients report clinically significant improve-ments in their quality of life, especially in the kidney-specific domains [22]. In a comparison with PD, patientsreported a similar perception of control over their kidneydisease and did not consider home HD as a more intrusivetreatment [26].

Paediatric home HD experience

The literature on paediatric home HD is scarce and limitedto single-centre experiences. Additionally, there is muchiteration on the theme of ‘home dialysis’ which may providedifferent frequencies of treatments and vastly different sol-ute clearance values per week, making meaningful compar-ison impossible. Nonetheless, available results are similar toadult data and include some pertinent paediatric specificmetrics, such as growth and nutrition (see Table 1).

The importance of prolonged time on dialysis in childrenwas demonstrated over a decade ago by Tom and colleaguesfrom Montreal, Canada, who demonstrated improvedgrowth without growth hormone in patients with intensive

HD three times weekly for approximately 5 h per treatment,to yield a spKt/Vof 2.0 and a caloric intake at 150 % of therecommended daily allowance for age [27]. Similarly,Fischbach et al. reported on catch-up growth in childrentreated in-centre with daily online haemodiafiltration. Thesechildren were not on any dietary restrictions and had a meanprotein diet intake (PDI) of 2.5 ± 0.2 g/kg/day [28].

Goldstein et al. [29] followed four patients (weight range38–61.4 kg) who received six-times-weekly HD at home,with an average of 2.5 h per treatment using the NxStage™system, for 16 weeks. The dialysis prescription was adjustedto deliver a standardised Kt/V of ≥2.1. All children demon-strated progressive reductions in both casual pre-dialysis BPand BP load by ambulatory blood pressure monitoring(ABPM) with concomitant discontinuation of antihyperten-sive medications in two patients. Serum phosphate levelsimproved without changes in phosphorus binder medicationrequirement. No significant overall improvement forpatient-reported health related quality of life (HRQoL)scores were observed, but parent-reported HRQoL scoresimproved in the Physical, Emotional and Psychologicaldomains [29].

The first report of nocturnal HD in children was bySimonsen et al. in 2000. These authors described four chil-dren, aged 10–19 years, who were treated with slow noctur-nal HD for 7–8 h, six nights each week, for a period of 5–55 months. Achieving a weekly Kt/V of 7.2–13.6, these

Table 1 Advantages and disadvantages of home haemodialysis

Advantages Disadvantages

Increased flexibility with dialysis times Dependent on parental/caregiver participation

Increased opportunities to attend school Caregiver burden

Reduced post dialysis ‘hangover effect’, improved recovery time Hospitalisation of the home with introduction of dialysis equipment andtreatment

Reduced intra-dialytic symptoms and hypotensive episodes Increased fistula trauma/complications with repeated, frequent cannulations

Liberalisation of fluid and diet restrictions Space required for dialysis equipment

Improved appetite Requirement for home modifications

Improved energy Increased utility bills (water, electricity, phone)

Improved quality of life Hypotension in anephric patients

Improved blood pressure control and reduced requirement forantihypertensives

Regression of LVH

Reduced dialysis induced myocardial dysfunctiona

Improved PTH control

Improved phosphate clearance

Lower doses/freedom from phosphate binders

Reduced erythropoietin requirementsa

Improved sleepa

More cost effective compared with conventional in-centre dialysis

LVH, Left ventricular hypertrophy; PTH, parathyroid hormonea Adult data only

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children had no fluid or dietary restrictions and actuallyrequired phosphate supplements orally to avoid hypophos-phatemia. Catch-up growth was achieved and quality of lifeimproved markedly [30].

Finally, Geary et al. [31] reported on six patients onhome nocturnal HD, aged 11–17 years. The first twopatients demonstrate reverse selection bias, as all alter-native dialysis options had failed them. After 1 year,one patient switched to a hybrid programme of homenocturnal HD on three consecutive days per week com-bined with one in-center 4-h-long HD session per weekfor respite purposes. No dropouts from the program orpatient deaths were reported. One patient developed afistula aneurysm from repeated use, in the absence ofsteal syndrome, and no line disconnections werereported. As a subjective measure, appetite improvedin all patients, and one patient converted from beingcompletely G-tube dependant to increasing oral intake to50 % of dietary requirements. BP control was variable.Two patients with native kidneys in-situ still requiredantihypertensives. However, three patients became hypo-tensive, requiring prophylactic midodrine to supporttheir BP for ultrafiltration. All patients were completelyfree from fluid and dietary restrictions, phosphate bind-ers were discontinued and all required supplementationwith phosphate in the dialysate, as well as higher cal-cium dialysate to prevent net negative calcium balance[31]. School attendance improved substantially in allchildren. Physical and psychological HRQoL scores im-proved in all patients in addition to a general feeling ofwell-being. However, caregiver’s feedback did highlightthe ‘burden’ they perceived in undertaking HD at home,reflecting the increased intensity of workload that ini-tially disrupted other family members and necessitatedestablishing a new routine within the home. The signif-icant additional responsibilities evoked anxiety. Themother of one patient was psychologically and emotion-ally worn out after 1 year and switched to a hybridprogramme as her son refused to revert back to in-centre dialysis. Finally, in a cost analysis of home nocturnalHD compared with conventional in-centre HD, a 27 %saving was seen for each patient dialysed at home [32]despite the increased ‘disposable’ costs of more frequentdialysis sessions

Infrastructure

Setting up a home HD programme requires careful planning,resources, dedicated staff and an appreciation of risk andgovernance issues. In such programmes, decisions need tobe made on the type of dialysis offered, for example noc-turnal versus short daily, long daily treatments or hybrid

prescriptions. Decisions also need to be made on the typeof dialysis machine and water source.

Finances

In a direct comparison of the cost of a dialysis session athome compared to in-center dialysis, savings can be as-sumed despite increased consumables costs due to the highstaffing costs needed to deliver the 1:1 or 1:2 nurse-to-patient ratio for in-centre paediatric dialysis. However, ini-tial set-up costs are incurred due to the purchase or leasingof a dedicated dialysis machine for each patient, the adapt-ing/converting of existing rooms/structures into an appro-priate training facility (ideally) and employing a dedicatedhome HD team. Support from hospital administration isnecessary to achieve this.

Staffing and around the clock support

Home HD is a relatively new therapy that places anactivity associated with a high clinical risk in the com-munity under the care of parents/caregivers and patients.In order to manage this risk it is crucial to recruit amultidisciplinary team to support the families not onlyduring office hours but also around the clock. Thecomposition of the team will vary depending on resour-ces, but at a minimum the team should include a hae-modialysis nurse, dialysis technician, nephrologist,dietician and social worker. The inclusion of other alliedhealth professionals, such as a pharmacist and psychol-ogist, as done at Great Ormond Street Hospital (GOSH),is preferable, as is the recruitment of community nurses,local paediatricians and general practitioners for addi-tional support, such as arranging for blood to be trans-ported to from patient’s homes to the local hospital.

Prior to going home families should be given writtenguidelines for normal ranges for a number of dialysis andphysiological parameters, values which require immediatecontact with the dialysis team and clear contact instructionsbased on ‘Out of Hours’ policy.

Follow-up is dictated somewhat by geography and med-ical stability, but once in the community patients shouldreturn to the clinic regularly, every 4–8 weeks, with pre-and post-dialysis blood samples prior to their clinic visit.Between clinics, patients should receive regular phonereviews by the nurse specialist.

Training and education

Companies supplying the dialysis equipment offer consid-erable teaching materials and expertise. However, signifi-cant adaption is invariably necessary for HD to become botha safe and relevant procedure for the paediatric population.

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Patients referred to the home HD team should undergo amulti-disciplinary assessment for suitability. Once acceptedinto the home HD programme, suitable training dates areassigned and families are advised of the usual 4- to 6-weekcommitment and the need to set aside this time for training.Preferably two people are trained, either both parents or oneparent and the young adult. Children should be encouragedto learn about the machine set-up, access and dialysis pre-scription and should be offered repeated training opportuni-ties once they are home. Training is initially started in theHD unit to ensure no acute complications, such as a dialyserreaction with the home circuit. If available, training shouldthen move quickly to a ‘family step-down’ training facilityon hospital grounds but away from the dialysis unit, whichhas been set up to simulate the home environment as muchas possible. If such a facility is not available, training shouldcontinue in the regular HD unit.

At the end of the training period families need to beformally deemed competent to perform home HD, both bythemselves and by the nurse specialist. A pre-requisite togoing home is to undertake one or more dialysis treatmentsunsupervised. Some programmes may also provide for thedialysis nurse to attend the home to provide technicalsupport for the first one or two treatments. A mandated6-monthly assessment by the nurse specialist at home pro-vides an invaluable opportunity for re-training at regularintervals to reinforce accurate technique and to catch lapsesin protocol which may lead to complications.

Remote monitoring is not universally employed, but ifavailable it may alleviate some patient or parental anxieties.Paediatric programmes will typically utilize an existingadult facility given the small numbers. Remote monitoringinitially required a dedicated phone line and modem, butwireless technology is supplanting this.

Dialysis equipment

Dialysis systems requiring home water conversions

A majority of the more traditional HD machines requirehome water conversions in order to produce the largevolumes of high-quality dialysate necessary for the di-alysis treatment. The cost of a home water conversioncan vary between renal units and can become a finan-cial barrier for children where transplantation is thepreferred renal replacement therapy and dialysis isviewed as a temporary interim measure. On average,home HD with water conversion is more cost-effectivethan in-centre HD—if patients stay on dialysis for morethan 14 months to offset training and setup costs [33].

Water conversion requires the installation of a coldwater outlet and a drain to allow the carbon filter,

reverse osmosis unit and dialysis machine to be fitted.Water quality is tested as per Renal Association Guide-lines [34]. This usually involves the patient testing theirwater for chloride every session and the dialysis tech-nician testing for chemicals, endotoxins and microbiol-ogy during routine servicing of the machine. Waterconversions and the use of reverse osmosis units donot come without problems, such as leaks and blockeddrains, and thus can become an additional source ofstress for families. Encouragingly, with an increasinginterest in home HD, companies are motivated andrising to the challenge of producing smaller and moreuser-friendly dialysis machines for the home setting.

Mobile HD system: NxStage™

The NxStage System One™ is a portable home dialysismachine that functions without home water modifications.Dialysate is provided in sterile pre-prepared 5-L bags orprepared at home using the NxStage PureFlow™ SL inte-grated water purification and dialysate production system.The latter produces 40- to 60-L batches of purifiedwater from ordinary tap water, which is then mixedwith sterile-filtered concentrate to produce AAMI (As-sociation for the Advancement of Medical Instrumenta-tion) quality lactate-buffered dialysate. The dialysatecircuit consists of a single extracorporeal circuit car-tridge with a polysulfone dialysis membrane.

During conventional HD, efficiency is gauged by clear-ance per unit time. The objective is to achieve clearance in aminimum period of time using high dialysate flow rates;consequently, the spent dialysate is unsaturated, and largevolumes of water are required to achieve the desired clear-ance. The NxStage™ is efficient in its use of dialysate, withthe spent dialysate being highly saturated. Thus, greaterclearance can be achieved at lower dialysate volumes. Theflow fraction is the ratio of effluent flow (spent dialysateplus ultrafiltration) divided by blood flow rate and corre-sponds to the degree of dialysate saturation. When thedialysate saturation approaches 100 %, the treatment doseis approximately equivalent to the volume of dialysate usedper session. With flow fractions of between 30 and 35 %, theclearance of small molecules, such as urea, is veryefficient, achieving dialysate saturations of 90–95 %.Clearance falls as the flow fraction increases, but to agreater proportion in larger molecules, such as creatinine[35]. Therefore, a balance has to be struck between dialysistime, blood flow rates and flow fraction to preservedialysate efficiency and the clearance of both small andmiddle-sized molecules.

We at GOSH typically start with a flow fraction of 30 %,dialysing for 5 h four times/week with a dialysate volume37.5 % of the estimated dry weight per dialysis session.

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Patient selection

There are no fixed or absolute criteria for selectingchildren for home HD, but parental/caregiver participa-tion and commitment are mandatory. The referral couldbe initiated for a number of reasons, including medical,social and/or education or simply because patients ex-ercise their rights to choose. A medical and psychoso-cial assessment of families is strongly recommended.We also believe that neither failed home PD nor med-ication or fluid non-compliance on conventional HDpreclude the possibility of home HD. Suggested criteriafor accepting patients into a home HD programme arelisted below. However, specific criteria may vary betweenprogrammes.

& Patient weight pf >18 kg (derived from volume ofextracorporal circuit and dialyser);

& Well-functioning vascular access;& No psychosocial concerns that cannot be managed in the

community;& Availability of a treatment supervisor;& Home of a sufficient size to accommodate the dialysis

equipment and 1 month’s worth of dialysis consumables;& In consideration of the reverse osmosis dialysis systems

at home, the ability to modify the water source;& Family household hygiene that does not compromise

patients risk of infection;& Child does not live in an area with frequent and pro-

longed disruptions to electricity supplies. An emergencysource of power must be available at all times.

One of the greatest criticisms of home HD research is thatoften the fittest and youngest patients are drawn to indepen-dent, home-based therapies, and there is no doubt that theseselection factors may influence outcomes. However, from apersonal perspective, both in Canada and the UK some ofthe sickest children have been recruited to a homeprogramme when traditional dialysis prescriptions havefailed in order to be able to provide more frequent andlonger dialysis sessions. Thus, based on our limitedpaediatric experience, we have introduced a reverse selectionbias at GOSH and Sick Kids, Toronto.

Prescriptions

One of the key drivers for families to agree to homeHD is the flexibility to perform the HD treatmentaround their own schedule. The impetus for clinicalteams is in improving patient outcomes and quality oflife. Attempts to achieve both goals with one dialysisprescription may be next to impossible, but some usefulguides do exist.

Frequent daily dialysis prescriptions typically compriseof 2–3 h of dialysis six to seven times per week. Suchprescriptions are very useful for working parents who can-not start dialysis until late in the evening or who need tocomplete treatments early in the evening due to eveningwork shifts. Such regimens seldom give complete freedomfrom phosphate binders but they can be useful in youngchildren who cannot tolerate long dialysis sessions, inpatients on parenteral nutrition or gastrostomy feeds andfor patients that do not tolerate aggressive ultrafiltration orare not optimally compliant with fluid restrictions. Of all thehome dialysis regimes, high-frequency prescriptions are themost expensive and fall in line with the higher dialysisconsumables cost.

Alternate-day, prolonged dialysis sessions typically con-sist of 5–6 h of dialysis, three or four times per week,usually in the evening. Such prescriptions may reduce—but rarely eliminate—the need for dietary and fluid restric-tions, but they may reduce dependence on phosphate bind-ers owing to improved phosphate purification. Alternate-daysessions reduce the treatment burden, offering both thepatient and their family time for social or recreational activ-ities and, thereby, a degree of respite. Such treatments arealso associated with an improved sense of well-being. Thiscan come at a cost when children start resenting having torelinquish their evenings for HD. Furthermore, after aninitial improvement in parathyroid hormone (PTH) andphosphate levels, an improved appetite and increased foodconsumption may cause levels to rebound.

Home nocturnal HD prescriptions are typically 8 h over-night, daily or alternate nights. Gentler dialysis with bloodflow rates of between 100 and 200 mL/min and dialysateflow rates of 200–300 mL/min (while maintaining a 2:1dialysate:blood flow ratio) will virtually eliminate adverseintra-dialytic symptoms. The extended time spent on dialy-sis provides the best purification potential of ‘uraemic tox-ins’, particularly phosphate and presumably middle-sizedmolecules. However owing to the non-selective nature ofHD purification, essential plasma components are also re-moved, resulting in a theoretical risk of deficiencies.Patients usually have complete freedom from dietary andfluid restrictions, and phosphate binders can be withdrawn,resulting in a reduced medication burden. Early onset hypo-phosphataemia is common and can be treated by oral sup-plements or by adding phosphate to the acid dialysateconcentrate as a sodium phosphate (Fleet) enema. To protectagainst a negative calcium balance, higher dialysate calciumlevels of 1.75 mmol/L are recommended from the outset.Some patients may develop persistently low BP, necessitat-ing prophylactic midodrine at the start of dialysis to supportthe BP, thus allowing ultrafiltration and reducing the risk ofthe circuit clotting. Dialysing overnight can induce anxietyboth in caregivers and children due to fears of disconnection

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and/or not hearing machine alarms. In an attempt to alleviatethese fears, some advocate equipping the dialysis machinewith a port for downloading treatment data onto a centralremote monitoring station via a personal computer or mo-dem [32]. An alternative is to use a baby monitor for thechild’s room, thus making it easier for parents to hearany alarms overnight. Access monitoring is highly recom-mended, using either enuresis alarm pads or more contempo-rary fistula specific monitors, such as HEMOdialert™(Anzacare, Nelson, New Zealand), which are sensitiveto fluid and the colour red. A cycler base fluid detectorwhich sounds an alarm if there are any leaks within the circuitcan also be used.

Dialysis adequacy

Traditionally, dialysis adequacy is assessed by urea clear-ance quantified as the urea reduction ratio or single pool oras equilibrated Kt/V. The European Best Practice Guidelinesfor HD recommends an eKt/Vof ≥1.2, which corresponds toa spKt/Vof approximately 1.4–1.5 [36]. However, especial-ly in children, there have been several challenges to thisdefinition of ‘adequacy’. Firstly, on a practical note, dialysispractices are becoming extremely variable between unitswith respect to frequency, duration and the use of convectiveclearance. Comparisons of efficacy require an alternativeapproach to small molecule clearance during a single dialy-sis session. The KDOQI 2006 adequacy group in theirClinical Practice Recommendations suggested using thestandardized Kt/V (std Kt/V) as a minimum standard ofadequacy for dialysis schedules other than three times perweek [37]. Std Kt/V models the delivered dose of dialysis toachieve the equivalent pre-HD treatment plasma urea nitro-gen (BUN) concentrations irrespective of the number of HDtreatments provided per week. It can be calculated directlyusing urea modelling, or it can be estimated from eKt/V,session length and number of treatments per week. Theoret-ical urea kinetic models predict that a std Kt/V of 2.1 isequivalent to a spK/V of 1.2 delivered three times weekly.However, Daugirdas et al. demonstrated inaccuracies of upto 13 % of the estimating equation-based approach forcalculating treatment Kt/V for higher dialysis frequencies[38]. More pertinent to children, the group also challengedthe suitability of using urea distribution volume as a denom-inator for dosing dialysis dose in children. NormalizingKt/V to body surface area, they found that most childrenunder 10 years of age would receive markedly less dialysisthan adolescent patients despite acceptable eKt/V and stdKt/V values. Theoretically, these children would requirelonger or more frequent dialysis sessions to achieve theirdesired dialysis dose [12]. Others have taken this a stepfurther, arguing that the success of dialysis regimen cannot

only be judged by the clearance of small molecules and thatthere are several other important end points, such as cardio-vascular health, quality of life and growth, to name a few,that need to be accounted for and assessed. We concur withthis statement and suggest a more holistic approach todialysis ‘adequacy’. Based on current technology and prac-tices, it is not unrealistic to aim for adequate growth, controlof anaemia, optimal BP and control of bone and mineraldisorders, absence of left ventricular hypertrophy and excel-lent psychosocial health.

Conclusion

Dialysis is associated with both short-term and long-termadverse consequences. However, there is hope that throughmanipulation of the dialysis prescription patient outcomescan be significantly improved. Quotidian dialysis pro-grammes at home, although varied, are producing resultsnever anticipated, and there is no doubt that renal transplan-tation is currently the gold standard for renal replacementtherapy. Children are in a privileged position where thepossibility of pre-emptive transplantation due to the avail-ability of living donors, particularly from parents, and pri-ority status on deceased donor lists makes transplantation arealistic option and the time on dialysis relatively short.However, there are some situations where transplantationmay be delayed such as sensitised children and for thesechildren a prolonged period on dialysis is a necessity.Reflecting specifically on paediatric dialysis therapies, eventhough data is scarce, the projected and demonstrable bene-fits of frequent and or prolonged dialysis are hard to ignore.This is especially true when the aim is to restore somedegree of normality into a child’s life. The simple butincredibly important achievement of children eating mealsalongside their families, with greater integration into schoollife and social activities, and the heightened general sense ofwell being—‘I just feel better’—cannot and must not beignored. Home HD demands a significant commitment fromthe medical team, patients and their families, but as a pae-diatric nephrology community we have a responsibility topromote, educate and actively recruit patients into quotidiandialysis programmes, based in the hospital or at home, toallow a greater proportion of children to receive their po-tentially life-long benefits.

Questions (answers are provided after the reference list)

1. One of the following is an absolute contraindication forhome HD:

A) A child weighing 19 kg;B) A child with co-existing congenital heart disease;

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C) A child whose home does not have a constant andreliable supply of electricity;

D) A child whose parents are separated and is lookedafter in two homes;

E) A parent with a history of depression.2. Compared with conventional in-centre HD, home HD

has several published benefits. Which of the followingstatements are incorrect in children:

A) Home HD improves blood pressure and reduces theanti-hypertension medication burden;

B) Children have an improved appetite;C) Children experience catch-up growth;D) Children’s fluid and dietary restrictions cannot be

lifted;E) Children cannot become hypophosphataemic.

3. Which one of the following statements relating to homeHD prescriptions is incorrect:

A) Frequent accessing of central lines by children ortheir carers increases the risk of infection;

B) Daily dialysis can become burdensome forfamilies;

C) Nocturnal HD offers the best chance of achievinggood phosphate control without the need for phos-phate binders;

D) Shorter, more frequent HD prescriptions may bestsuit children prone to intra-dialytic hypotension;

E) Flexibility around the timing of the treatment ispossible providing children do not go longer than48 h without dialysis.

4. The following are necessary when setting up a homeHD program in children, except:

A) Multidisciplinary team;B) Step-down training facility;C) Additional finances for the initial set-up costs;D) Out of hours support for families;E) Dialysate fluid quality that meets recognised na-

tional and/or international standards.5. Which of the following statements relating to dialysis

adequacy are correct?

A) Equilibrated Kt/Vurea is the best marker of dialysisadequacy;

B) Standardised Kt/V is simply the product of thenumber of weekly dialysis sessions multiplied bythe single pool Kt/V of a single session;

C) Theoretical urea kinetic models predict that a stand-ardised Kt/Vof 2.1 is equivalent to a single pool K/Vof 1.2 delivered three times weekly;

D) In children growth is an important measure ofdialysis adequacy;

E) The European Best Practice Guidelines for HDrecommended an equilibrated Kt/Vurea of ≥ 1.4.

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Answers:

1. C2. D, E3. A4. B5. C, D

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