In-home and nocturnal dialysis offer better outcomes and freedoms
"There's a huge quality of life benefit in how patients feel after nocturnal dialysis. It's a functional improvement," says Rusty Brantley, MD, with Nephrology Associates.
Though exactly the same process as diurnal dialysis, nocturnal sessions last eight hours instead of four. "It's slower, so you get much better cleaning of the blood," Brantley says. "With long dialysis, evidence shows they have the same survival rate as if they had a cadaveric kidney transplant."
Nocturnal sessions start around 5:00 or 6:00 in the evening. Three sessions per week are needed, just like with diurnal sessions. Patients who can't sleep through the nighttime dialysis are offered medications to help.
"The patients who work, go home after the session, sleep another three hours or so, and then go to work," Brantley says.
Following the longer treatment, patients feel noticeably better than after the shorter day sessions. "They tell me they can now look after their grandkids or work all day after a session. It improves their sleeping and eating too. They can actually do physical things," Brantley says.
Not only does their appetite tend to increase, but patients often come completely off their phosphorous binders and dietary restrictions. "You find that the levels normalize, so they can eat about what they want to, because the blood is so much cleaner."
In Birmingham, Nephrology Associates and UAB are the only clinics offering nocturnal sessions right now. Brantley says their Bessemer clinic has 24 machines. They're looking into offering sessions at their Hoover location in the next few months should enough patients show an interest.
Only transportation hinders a patient from utilizing nocturnal dialysis. "Anybody who can get here can come. Diabetics, older patients, it doesn't matter. The big issue is transportation because of the odd time needed for the drive home," Brantley says.
Time has become the determining factor for quality dialysis. Brantley feels that once the health system sees the outcome difference, longer sessions and nocturnal options will be more popular.
"When I was training in 1996, we'd dialyze two to three hours. Now for day sessions, we do four hours minimum," Brantley says. "Now we're looking at time. That's the new part of dialysis."
In another recent dialyzing option open to Birmingham patients, time again plays a factor. But with in-home dialysis, the sessions are about half the length of traditional inpatient ones, though twice as frequent.
Two years ago, only one patient at Nephrology Associates did home hemodialysis. Now they have 15 in-home patients, with a constant inflow of new ones, thanks to the availability of the NxStage dialysis machine.
Previously used primarily in intensive care units for those with low blood pressure, "it's slow and gentle, and you could run it throughout the day and night," says Harry Giles, MD, medical director of home training units at Nephrology Associates.
The cartridge-based system makes it easy to clean and load. "For cleanup, you basically turn off the machine, take the cartridge out, and throw out the bag and the tubes," Giles says. "There's no winding a whole bunch of tubes. It doesn't take much time to break the machine down or set it up."
The entire machine is only about 18-inches square, making it more amenable to home placement. The cartridges and other supplies arrive at the home regularly. "It's much more patient-friendly," Giles says.
The machine runs an array of safety checks before beginning and throughout the session. "It doesn't differ really from the inpatient process. It's a different way of mimicking the same mechanism," Giles says.
Because it runs more slowly, in-home patients must dialyze five to six times a week. However, the sessions last only two-and-a-half hours versus the four-hour inpatient sessions. The pay-offs are no transportation needs to a center, flexible schedule, and the comfort of home.
In-home dialysis does require a partner willing to insert the needle and monitor the sessions. "A lot of family members are excited to have the patient home more, and they take pride in giving that care," Giles says. "Plus the patient has more free time and can travel more easily by taking the machine with them."
Giles says some patients are apprehensive about delivering their own care. "They fear the procedure will go wrong or they'll do something wrong. Or they worry about the burden of the procedure on their partner."
But should a patient or their caretaker need a break, they can schedule some sessions at the dialysis center instead. "Burn-out is a natural human reaction to doing something on a routine basis," Giles says. "But we'll work with them on that."
Prior to taking a machine home, partners and patients attend trainings at a center and do several weeks of practice sessions under a trainer's supervision.
Medicare, says Giles, offers less reimbursement for home dialysis, which is more expensive. But they're currently reevaluating home therapy, because patients stay out of the hospital and feel better longer.
"The important thing is to give them more options," Giles says. "When they have lot of options for dialysis, then they have more options for being independent. That's what I'm excited about."