Nocturnal home hemodialysis: which of your patients should choose this modality?

Abstract

Nocturnal home hemodialysis (HD) was conceived in the 1960s, but fell out of favor in the 1970s, only to be resurrected in a modified form in the 1990s. This modality is now used by patients on 4 continents, but still accounts for only a very small number of patients who receive chronic HD therapy. Nocturnal home HD provides a weekly Kt/V urea in the range of 4.5-6, and provides superior clearance of a number of middle molecules as well as some protein-bound and charged molecules. The first randomized trials of nocturnal home HD compared to conventional 3 times per week HD were performed in the first decade of the 21st century. In the Alberta trial, 52 patients were randomized to either nocturnal home HD conducted 5-6 times per week or conventional HD conducted 3 times per week; the patients were followed for 6 months. In this trial, subjects who received nocturnal home HD had a decrease in left ventricular mass, and improvement in the management of hypertension and hyperphosphatemia, but no significant benefit in either quality of life or anemia management. There was a decrease in systolic blood pressure, despite a decrease in the number of antihypertensive medications prescribed. There was also a decrease in serum phosphorus levels as well as a marked reduction or elimination of phosphate binders in more than two thirds of the nocturnal subjects. In the Frequent Hemodialysis Network study of Nocturnal Hemodialysis, 87 patients were randomized to either nocturnal home HD (6 times per week) or conventional (3 times per week) dialysis, and were followed for 12 months. Results from this trial will be published in 2011. It is likely that the results from these 2 trials will influence the update to the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative HD guidelines that will be published in 2012.