"Quotidian nocturnal hemodialysis - description and indications."

Andreas Pierratos MD FRCPC

Humber River Regional Hospital , University of Toronto, Toronto, Ontario, Canada

Modality description
Quotidian nocturnal hemodialysis is preformed 6-7 days per week at home at night usually for 8 hours during sleep by the patient or a partner(1). The average blood flow is 200-300 and dialysate flow is 300 ml/min. Any dialysis machine and dialyser can be used. In comparison to conventional hemodialysis dialysate on nocturnal hemodialysis contains lower bicarbonate, average 32 mmol/l, higher calcium, average 1.6 mmol/l and sodium phosphate is added, average 0.5 mmol/l in the majority of the patients. Heparinization is similar to conventional hemodialysis.

Dialysis access
Both central venous catheters as well as fistulas and grafts can be used on nocturnal hemodialysis(1). Most patients with fistulas follow the buttonhole technique of cannulation (same-hole cannulation) preferably using blunt needles. An 'enuresis' alarm sensor taped on the fistula needles alerts the patient to possible blood leak. Several centers have been monitoring patients 'live' while on nocturnal hemodialysis through a telephone or an Internet connection(2).

Patient selection criteria.
The main selection criteria for training for home hemodialysis are the ability and willingness to learn as well as adequate space for the machine and supplies. Serious co-morbid conditions and hemodynamic instability have not been contraindications for daily hemodialysis. Training for home dialysis lasts on average for 5-6 weeks for previously untrained patients.

Kinetics / solute removal
The most popular yardstick of dialysis dose useful in comparing dissimilar dialysis methods and native kidney function is the standard Kt/V (stdKt/V) which uses the mid-week pre dialysis rather than the time average urea concentration for the calculation(3). The stdKt/V following the DOQI guidelines for conventional hemodialysis is 2.0. Short daily nocturnal home hemodialysis with the same weekly duration with conventional hemodialysis gives a stdKt/V of 3.5 and nocturnal hemodialysis 6 nights a week provides a stdKt/V of about 5(4). The four-fold increase in dialysis time per week over conventional hemodialysis increases the removal of middle molecules. ß2M removal on nocturnal hemodialysis is four-fold higher than conventional hemodialysis(5). Nocturnal hemodialysis was associated with a 6.0 µmol/L lower mean total homocysteine level when compared to conventional hemodialysis(6). Weekly phosphate removal is twice as high as on conventional hemodialysis(7).

QOL
All the quality of life studies have shown improvement upon conversion to daily hemodialysis(8;9). Patient testimonials have been striking.

Cardiovascular parameters
As in short daily hemodialysis blood pressure (BP) control has been excellent without the use of antihypertensives(10;11). Although decrease in the extracellular volume is a significant factor for BP control, there is evidence that peripheral vasodilatation is the dominant mechanism of BP control on quotidian nocturnal hemodialysis. Decrease in the left ventricular mass has been reported on both short daily hemodialysis and daily nocturnal hemodialysis(11;12). Furthermore, nocturnal hemodialysis was associated with a significant improvement of left ventricular function(13). Finally there is evidence of improved endothelial function on nocturnal hemodialysis(14).

EPO dose and anemia control
The decrease in EPO dose by about 20-30% while there is a significant increase in hemoglobin(11).

Calcium, phosphorus metabolism and bone disease.

Serum phosphate control normalizes on nocturnal hemodialysis without the use of phosphate binders while on unrestricted diet(7). Furthermore more than 50% of the patients require addition of phosphate into the dialysate in the form of sodium phosphate(2). In one patient massive extraosseous calcifications dissolved(15). High dialysate calcium is needed to prevent to preserve calcium balance and prevent decrease in mineral bone density(16). PTH levels decreased significantly through the use of high dialysate calcium(17).

Nutrition
Improved appetite and weight gain were reported on nocturnal hemodialysis(1;18). Despite the increased aminoacid loss into the dialysate there is preservation or increase in total body nitrogen while on nocturnal hemodialysis(19). No change in serum albumin was reported(1). Recently several nutritional parameters improved more on short daily than on nocturnal hemodialysis(20). More data is needed.

Sleep
Sleep studies were done prior and after the 14 patients were converted to nocturnal hemodialysis. In seven patients with sleep apnea conversion to nocturnal hemodialysis normalized the frequency of apnea/hypopnea episodes(21). Therefore daily nocturnal hemodialysis corrects sleep apnea associated with chronic renal failure. There was no effect on the periodic limb movements or daytime sleepiness(22).

Finances
Increased frequency of dialysis obviously increases the direct cost of dialysis. Prospective studies showed savings of about 6,000 (U.S.) per year when patients are converted to quotidian nocturnal hemodialysis(23). This is mainly related to decreased labor costs, hospitalization rates and medication costs. The cost utility of quotidian nocturnal hemodialysis was also found to be significantly higher than conventional hemodialysis(24).

Obstacles
The main obstacle in the expansion of daily hemodialysis seems to be the increased direct cost of provision of daily hemodialysis. Another obstacle to the expansion of home daily hemodialysis frequently is the absence of infrastructure for home hemodialysis. Most of the dialysis centres do not have home hemodialysis programs. Also most of the current hemodialysis machines are cumbersome for patients. New hemodialysis machines have been produced and existing machines were modified to become 'patient-friendly'.

Indications for quotidian nocturnal hemodialysis.
Although most of the qualities of nocturnal hemodialysis are shared by short daily hemodialysis and long intermittent hemodialysis, there are several indications for nocturnal hemodialysis:

• Large body size.
• Uncontrolled hyperphosphatemia, extraosseous calcifications or severe hyperparathyroidism.
• Sleep apnea.
• Significant hemodynamic instability / hypotension on hemodialysis.
• Severe heart failure.
• Intractable ascites.
• Patients wishing to have the day free, usually to be able to work.
• Poor vascular access blood flow or when a single needle system is preferable.
• Presence of dialysis related amyloidosis (speculative).

REFERENCES

(1) Pierratos A, Ouwendyk M, Francoeur R, Vas S, Raj DS, Ecclestone AM et al. Nocturnal hemodialysis: three-year experience [see comments]. J Am Soc Nephrol 1998; 9(5):859-868.

(2) Pierratos A. Nocturnal home haemodialysis: an update on a 5-year experience. Nephrol Dial Transplant 1999; 14(12):2835-2840.

(3) Gotch FA. Modeling the Dose of Home Dialysis. Home Hemodial Int 1998; 2:37-40.

(4) Suri R, Depner TA, Blake PG, Heidenheim AP, Lindsay RM. Adequacy of quotidian hemodialysis. Am J Kidney Dis 2003; 42(1 Suppl):42-48.

(5) Raj DS, Ouwendyk M, Francoeur R, Pierratos A. beta(2)-microglobulin kinetics in nocturnal haemodialysis. Nephrol Dial Transplant 2000; 15(1):58-64.

(6) Friedman AN, Bostom AG, Levey AS, Rosenberg IH, Selhub J, Pierratos A. Plasma total homocysteine levels among patients undergoing nocturnal versus standard hemodialysis. J Am Soc Nephrol 2002; 13(1):265-268.

(7) Mucsi I, Hercz G, Uldall R, Ouwendyk M, Francoeur R, Pierratos A. Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis. Kidney Int 1998; 53(5):1399-1404.

(8) Brissenden JE, Pierratos A, Ouwendyk M, Roscoe JM. Improvements in quality of life with Nocturnal Hemodialysis. J Am Soc Nephrol 9, 168A. 1998.

(9) Heidenheim AP, Muirhead N, Moist L, Lindsay RM. Patient quality of life on quotidian hemodialysis. Am J Kidney Dis 2003; 42(1 Suppl):36-41.

(10) Woods JD, Port FK, Orzol S, Buoncristiani U, Young E, Wolfe RA et al. Clinical and biochemical correlates of starting "daily" hemodialysis. Kidney Int 1999; 55(6):2467-2476.

(11) Chan CT, Floras JS, Miller JA, Richardson RM, Pierratos A. Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis. Kidney Int 2002; 61(6):2235-2239.

(12) Fagugli RM, Reboldi G, Quintaliani G, Pasini P, Ciao G, Cicconi B et al. Short daily hemodialysis: blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients. Am J Kidney Dis 2001; 38(2):371-376.

(13) Chan C, Floras JS, Miller JA, Pierratos A. Improvement in ejection fraction by nocturnal haemodialysis in end-stage renal failure patients with coexisting heart failure. Nephrol Dial Transplant 2002; 17(8):1518-1521.

(14) Chan C, Harvey PJ, Pierratos A, Miller JA, Floras JS. Short-term blood pressure, noradrenergic and vascular effects of nocturnal hemodialysis. Hypertension. In press.

(15) Kim SJ, Goldstein M, Szabo T, Pierratos A. Resolution of massive uremic tumoral calcinosis with daily nocturnal home hemodialysis. Am J Kidney Dis 2003; 41(3):E12.

(16) Al Hejaili F, Kortas C, Leitch R, Heidenheim AP, Clement L, Nesrallah G et al. Nocturnal but not Short Hours Quotidian Hemodialysis Requires an Elevated Dialysate Calcium Concentration. Journal of the American Society of Nephrology 2003; 14(9):2322-2328.

(17) Pierratos A, Hercz G, Sherrard DJ, Copland M, Ouwendyk M. Calcium, Phosphorus Metabolism and Bone Pathology on Long Term Nocturnal Hemodialysis. J Am Soc Nephrol 12, 274A. 2001.

(18) McPhatter LL, Lockridge RSJ, Albert J, Anderson H, Craft V, Jennings FM et al. Nightly home hemodialysis: improvement in nutrition and quality of life. Adv Ren Replace Ther 1999; 6(4):358-365.

(19) Pierratos A, Ouwendyk M, Rassi M. Total Body Nitrogen Increases on Nocturnal Hemodialysis. J Am Soc Nephrol 10[September], 299A. 1999.

(20) Spanner E, Suri R, Heidenheim AP, Lindsay RM. The impact of quotidian hemodialysis on nutrition. Am J Kidney Dis 2003; 42(1 Suppl):30-35.

(21) Hanly PJ, Pierratos A. Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal hemodialysis. N Engl J Med 2001; 344(2):102-107.

(22) Hanly PJ, Gabor JY, Chan C, Pierratos A. Daytime sleepiness in patients with CRF: impact of nocturnal hemodialysis. Am J Kidney Dis 2003; 41(2):403-410.

(23) McFarlane PA, Pierratos A, Redelmeier DA. Cost savings of home nocturnal versus conventional in-center hemodialysis. Kidney Int 2002; 62(6):2216-2222.

(24) McFarlane PA, Bayoumi AM, Pierratos A, Redelmeier DA. The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis. Kidney Int 2003; 64(3):1004-1011.