Icon - Home haemodialysis

Home haemodialysis

Home haemodialysis (HHD) is done at least three times a week and lasts for at least four to five hours. It can also be done overnight. Home HD offers a lot of flexibility around the timing of your dialysis and how many hours you can do. Doing some additional hours is better for your health.

Currently, in Australia, about one in ten people on dialysis are on home haemodialysis.

If you are going to do home HD you will need to learn to manage your own dialysis. The equipment is all provided free to your home. If you think home haemodialysis may be an option you should learn as much about it as you can. Please read all the topics in sections set out below.

Refer: Home Dialysis: A Treatment Option fact sheet

Choosing the right option
You are ready to choose when you’ve learned everything that you need to know about each option. That means finding out the information that’s relevant and understandable to you.

‘My Kidneys, My Choice’ Decision Aid
This is a useful decision aid that will help you to make your choice. You can find a lot of helpful advice, including information about the My Kidneys My Choice decision aid. View the pdf copy of this resource for patients here.

Your life and Home HD

Your life and Home HD
Flexibility, freedom and control are words often used by people on home haemodialysis (Home HD).

The alternative, haemodialysis at hospitals or satellite dialysis units, involves strictly attending three appointments a week, for four to five hours at a time.

At home, in consultation with your dialysis healthcare team, you can choose how often and for how long you dialyse. Many people actually choose to dialyse longer hours, because they feel healthier and recover quicker when they finish dialysis.

Dialysing alone or with support
If you can dialyse independently and don’t have any health risks that might lead to problems when on the machine, you may be able to dialyse alone.

Some people like to have a support person (or carer) in the home to help them set up and complete the dialysis. Others like to have, or perhaps need, a support person with them for every treatment.

If you choose to dialyse alone, having a phone is essential so you can call for support if required. Ask your dialysis healthcare team for advice and more information about dialysing alone.

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The length of time Home HD sessions take
When you’re starting out, Home HD preparation takes about one hour, but in time you will become quicker. About 15 minutes are spent on each of the following steps:

  • putting the lines on the machine and preparing the needling equipment
  • connecting the dialysate and priming the lines
  • organising yourself and checking your weight and blood pressure
  • inserting the needles and connecting to the machine.

Once you’re on the machine you can perform numerous activities that don’t require you to move around, including reading, watching TV, working on a laptop, and catching up on sleep. Some people do simple exercises with modified equipment.

Where to do Home HD
Home HD is usually done at home in the same room each time. You can choose if that room is the lounge room, a bedroom or a specially converted room.

Some people have installed their machine in a caravan or boat, providing them with freedom to travel. 

Food and fluid restrictions
The more you dialyse, the less food and fluid restrictions you will have. 

Phosphate, potassium and fluids are commonly restricted for those doing haemodialysis three times a week, which is usual if the treatment is at a dialysis unit.

If you’re on overnight dialysis, you can often eat or drink most things most of the time. 

Work and Home HD
You can work while on Home HD, because you can choose to do your dialysis at home during the night. Taking time off for the training may be tricky, but most dialysis units have some flexibility in their training schedules. 

If you have to travel for work, however, you’ll need to organise to dialyse at a dialysis unit. Whether at home or at a unit, working on a laptop while on the machine is common practice.

Swimming, sport and exercise
You can swim, play sport or exercise while on Home HD. The only limitations will depend on your fitness. If you play contact sport, it’s important to ensure the fistula is protected. 

Intimate relationships
You can continue to have intimate relationships while on Home HD. 

Travel and holidays
With planning, and maybe some determination, you can travel and take holidays while on Home HD. It may involve appointments at dialysis facilities but some people have done Home HD in amazing places.

You can see more about Home HD and holidays in this information booklet here.

Useful resources
‘An Introduction to Home Dialysis’
This easy-to-read booklet focuses on all types of home dialysis and how they will fit into your life. You can download the booklet - download here.

‘What activities can I do now that I am on dialysis?’
This short video presents patient stories about the activities these people continue to do, now that they are on dialysis. It was produced by the Princess Alexandra Hospital, Brisbane, with support from the South Queensland Renal Clinical Network. You can watch this video here.

How home HD works

How home HD works
All haemodialysis requires vascular access, a dialysis machine and a dialyser. Your blood flows from your vascular access and is pumped through lines around the dialyser on the dialysis machine, and the clean blood is returned to your body.

If you’d prefer to watch a video about how home HD works go the ‘Useful resources’ below.

Vascular access via a fistula
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A fistula is the direct connection of an artery to a vein. The procedure is performed by a surgeon during day surgery and should be done at least six weeks before dialysis is needed.

With a fistula, blood flows quickly from the artery, making the vein wider and providing good blood flow for dialysis. 

The fistula is where you put in the needles for the dialysis. Two needles are required, one to remove the blood and the other to return it.

Graft
A graft is an artificial vein or tube that is placed in the arm or leg and attached to one of your arteries and one of your veins, so the needles can be put in for dialysis.

A graft is only used if your own veins are too weak for a fistula to work.

Central venous catheter (CVC)
In a few people a long-term CVC, also known as a dialysis catheter, is used. This a soft plastic tube that is placed into a large vein in the chest, and splits in two to take the needles for the dialysis. 

With a CVC there can be an increased risk of infection and it can be more difficult to manage at home; however, a number of people prefer to use a CVC. Discuss this with your dialysis healthcare team to see if it’s an option for you.

The dialysis machine
The machine is the engine that runs and controls your dialysis. In Australia there are various companies supplying machines for home dialysis. These include Fresenius Medical Care, Baxter/Gambro Healthcare and, in some states, Nxstage.

The machines all perform the same function in slightly different ways. Your dialysis healthcare team can advise what machines are available and which is most suitable for you.

The machine is prepared with lines, dialysate and a dialyser and has safety features to detect air and blood clots. You program the machine according to the hours of dialysis and amount of fluid to be removed.

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The dialyser
The dialyser cleanses your blood, performing the work that your kidneys would usually do. The blood is pumped by the dialysis machine through the blood lines to the dialyser and back to you.

Another name for the dialyser is ‘artificial kidney’. It is 20 to 30 centimetres long and contains thousands of tiny fibres (like hairs) that have microscopic holes. The blood travels through these fibres and is cleansed by a special solution known as dialysate.

The dialysate
Very clean water is required to make the dialysate. For most machines, a water treatment system is used. The water may go through a series of filters until it is clean enough for dialysis.

The water is then delivered to the dialysis machine. At this point, the machine mixes the water with a special concentrate, provided in a five-litre bottle or as a powder, to form the dialysate. Around 1000 litres of water are used for each treatment.

The dialysis session
Each dialysis session involves preparing a dialysis machine with dialysate and the blood lines, which are connected to the dialyser and, if required, heparin (a drug that stops the blood from clotting). Two needles are placed into the fistula or graft, unless you are using a CVC at home.

The needles are connected to the blood lines. During each session, the machine is programmed by you to remove your extra fluid.

Diffusion allows certain molecules to move through the dialyser and into the dialysate. Ultrafiltration removes the water from your blood through the dialyser fibres and into the dialysate. The used dialysate then goes down the drain.

Putting in the needles
Putting in the needles (known as cannulation) can concern many people. The needles are sharp and quite big. You can use a local anaesthetic but many people soon stop doing this. Please note that most people, once they can put in their own needles, tend not to let anyone else do it for them.

Some people with a needle phobia have successfully had hypnotherapy to overcome the fear.

If you’re worried about the needling, ask your dialysis healthcare team if they can put you in touch with someone on Home HD who can share their experience.

Haemodiafiltration (HDF)
HDF Is a special form of haemodialysis in which the extra water from the dialysate goes into and out of the dialyser.

The advantage is that larger waste molecules are removed from the blood. It’s thought that removal of these molecules may keep you healthier. Longer hours of dialysis at home also has the same positive effect.

However, if you’re going to be on home dialysis for many years and machines are available that have the HDF function, then it may be an option for you. 

If you’re interested, check with your dialysis healthcare team if an HDF machine is available and whether it would be beneficial for you.

Risk of blood clots
If required, the dialysis healthcare team will prescribe heparin, a drug that stops the blood from clotting. It will be administered by a syringe attached to the dialysis machine, or by injection.

If you need heparin, it can be obtained from a pharmacy on prescription, which you may need to pay for.

Useful resources

‘Home Haemodialysis’
This informative presentation, illustrated with photographs, shows a Home HD patient and his wife  setting up a machine and starting dialysis. You can download this presentation here.

‘How does HD work?’
This short video explains Home HD in simple terms. It was produced by the Princess Alexandra Hospital, Brisbane, with support from the South Queensland Renal Clinical Network. You can watch the video  on Vimeo here.

Day or night

Day or night dialysis
Home HD can be done during the day or at night. 

Options for dialysing during the day
The minimum number of dialysis treatments per week is three. The minimum number of hours per week can vary but generally is 12, so that usually means sessions of four or five hours. While this is the usual regime at dialysis units, for many people it’s often not enough dialysis for healthy outcomes. 

The most popular Home HD regimes involve dialysis on alternate days  or four times a week in total. You choose the days off. It doesn’t matter if you prefer the morning, afternoon or evening. Also, you can change the time you dialyse from day to day. Some people choose five or six sessions a week but often for shorter hours each time.

Options for dialysing at night (nocturnal)
As an option for Home HD, nocturnal dialysis is gaining popularity. It allows you to use your sleep time as dialysis time. You can dialyse more slowly and more often, up to eight hours, without compromising your daytime activities.

Having more dialysis means more waste products and water are removed, which means you should feel better and be able to eat and drink more. A healthy eating pattern is always recommended.

As with daytime dialysis, you need at least three treatments per week. The most popular options are every second night (four nights a week in total).

Research into day and night dialysis and longer hours
Studies generally indicate that more haemodialysis is better, and nocturnal usually allows more.

The benefits of longer hours or more frequent haemodialysis appear to be:

  • less need for blood pressure medications
  • less need for phosphate binders
  • more options for diet and fluids
  • better sleep patterns
  • less occurrence of restless legs
  • better heart health
  • reduced risk of death.

This list of benefits is based on anecdotal evidence, as there is very little research that randomly compares daytime dialysis against nocturnal dialysis.

In discussions with people on Home HD who dialyse for longer hours, many say they feel better and can enjoy life more.

Sleeping while dialysing at night
You can sleep while dialysing with the machine but some people may take a little while to adapt.

There’s a gentle hum from the machine and the water treatment, and alarms will sound if there are problems with any of the pressures or blood flow.

When converting to nocturnal Home HD, it’s advisable that you plan a quiet week to allow yourself time to get used to the machine and the new routines.

The effect of extra treatments on the fistula
When comparing five or six dialysis sessions a week to three times a week, some research studies have found there are slightly more problems with infections and blockage of the fistula, which may require surgery.

Talk to your dialysis healthcare team about the best way to manage your fistula and any risks that extra dialysis may create. 

Useful resources

‘An Introduction to Home Dialysis’
This easy-to-read booklet focuses on all types of home dialysis and how they will fit into your life. You can download it here.

‘Renal dialysis – coping with kidney failure’
This video, produced in the UK, tells the story of Maddy, who manages her Home HD at night. You can watch the video here.

‘Nocturnal Home Haemodialysis’
The Department of Renal Medicine at the Geelong Hospital has a website with extensive information about nocturnal Home HD. You can visit this site here.

Getting started

Getting started on home HD
Before you can start Home HD you will need to meet and have discussions with your Home HD nursing team.

Suitability of your home
Most homes are suitable. Space is always a consideration but Home HD equipment has been installed into homes as small as one-bedroom units. Where there’s a will there’s a way. 

Requirement for upgrades to electricity or plumbing will be assessed by a specialised technician, but for the majority of homes these are usually minimal. Most changes that are dialysis-specific are paid for by the healthcare system but it’s important to check if there’ll be any cost to you.

Tank water can be used for Home HD but the quality and volume of water will be checked by the technician, who will advise if your tank system is suitable. New portable home dialysis technologies becoming available in Australia are reducing the need for large volumes of water.

Some people choose to put a special bed or chair in for their dialysis room, and extra cupboards for supplies. This is up to you, but you may have to pay for these facilities yourself.

If you are renting, you will need written permission from the owner for any necessary changes around the house. Your dialysis healthcare team should have a draft letter than can be used. Landlords and public housing departments usually agree to the changes, as they are usually minor and not noticeable once the equipment is removed if you leave.

When your own home is not suitable, in some states community housing is provided. Check if this is an option for you. Your dialysis healthcare team will know who to contact.

Types of vascular access
Your kidney specialist should refer you to a surgeon for your vascular access surgery. The preferred timing is for a fistula or graft (artificial vein) to be created six to eight weeks before dialysis and needling begins.

Most people have an arterio-venous fistula as it provides the best access, and usually has the least complications. It will be created in the left or right arm, depending on the suitability of the blood vessels and which is your dominant arm. The surgeon will help you choose the most appropriate location for your fistula. A specialist nurse known as the vascular access nurse may organise your surgery.

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If your blood vessels are damaged or weak, a graft may be recommended. This can be in your arm or leg.

The final option is to have a central venous catheter (CVC), which offers the advantage of immediate use. The CVC may be temporary or permanent. CVCs can work well but do have an increased risk of infection if not managed carefully. They also have a higher incidence of blockage.

Length of time for surgery
When planning surgery for a fistula or graft you should anticipate it will take a day or an overnight stay in hospital, but this can vary depending on your general health and your surgeon’s advice. 

The surgery may be performed with a local or general anaesthetic. 

After surgery you will notice a buzzing feeling in the vascular access, which means that it’s working. This can be felt by you and heard with a stethoscope.

Pain after surgery
As with any surgery, you may have some bruising and short-term discomfort, which can be managed with mild painkillers. If you have long-term pain or excessive bruising, you should let your nurse or doctor know.

Looking after the fistula
The first six weeks are critical to developing a strong fistula. For the first few days, the practice of medical teams in most hospitals is to apply a protective dressing. You may have stitches, which will be removed after seven to ten days. 

If you have a central venous catheter (CVC), the dressings will initially be applied by the medical team and then they may teach you how to care for the catheter yourself.

You will be taught how to monitor and care for your fistula or graft, and it’s important to contact the hospital if it stops working. You might also be taught some simple exercises to help strengthen the blood vessels.

Starting dialysis
If you’re not yet on dialysis, you will continue to have blood tests and your general health monitored. The right time to start dialysis will be a decision that you and your healthcare team make together. 

Dialysis may be started at a training centre, hospital or dialysis unit. Different locations suit different people and the choice is often determined by lifestyle, health issues and waiting lists at the training sites.

Wherever you start, using the time wisely to learn as much as you can about the dialysis process can shorten your training time.

Help with accommodation and travel

If you’re in a rural or remote region, there are patient-assisted transport schemes that provide support with transport and accommodation. If you live in a town or city, you may be eligible for support such as community vehicles, taxi voucher schemes and volunteer driving services. 

Your Home HD nurses can provide advice, or refer you to a social worker, if transport or accommodation is a difficulty for you. You can see more about travel assistance schemes here.

Useful video

‘Home haemodialysis requirements’ is
A video providing a summary of what you will need when you start Home HD. It was produced by the Princess Alexandra Hospital in Brisbane. You can watch the video here.

Training for home

Training for home
Training is a key part of living with Home HD and here we provide a range of information that you may find helpful. 

Starting training
To learn Home HD you will usually need to go to a specialised training clinic. This may be in a hospital or community setting. Often home training is attached to a dialysis unit. 

The Home HD nurses are specialists in this treatment and, as well as helping you to learn, they support you at home and can become an extended part of your family.

If you’re already on another type of dialysis, the healthcare team at many dialysis units will help you to learn the basics of Home HD, encourage you to do your own needling, and set up the machine. This ‘pre-training’ can shorten your time attending a training unit. 

Some people are trained in their own home. If you think this would be better for you, ask the Home HD nurses at your nearest training clinic if the service is available.

You can locate these clinics in your area using our Dialysis Unit Guide here.

Home HD support person
With Home HD, it’s usual to choose someone you live with to be your support person. They will work with you to complete the treatment, assisting you in certain parts of the process. Usually they are only responsible for helping, not for the complete treatment.

It’s best for you to be as independent as possible in your treatment. There may be a reason, however, why you cannot do much of the treatment but still prefer to be at home. 

If so, let your Home HD nurses know there’s someone you’d like to attend training with you. It may also be possible for you to have a private nurse help you at home. While this is not common, a nursing or carer service may be available in your area.

Organising work and training
If you are working and do not have paid leave available, your Home HD training team or a social worker will be able to advise you about options for payment during your training period, by your employer or Centrelink.

The training team may be able to arrange some training out of hours so that you can continue working, at least part time.

Download our information booklet about finance on dialysis here.

Learning to do Home HD
On average, training takes six to twelve weeks, or 20 to 30 training sessions. There can be three to five sessions per week, and evening training or weekend training may be available. Talk to your training team to discuss your options. 

As part of the training process, one hour is allowed before and after each practice treatment for preparation and discussion. This may sound like a lot of training but it’s a great investment in your future health and wellbeing.

Training is taken one step at a time, and at your pace. You can make a request for family members or support persons to be involved, but they do not usually attend all of the training. 

Performing your Home HD at home without the nurses only happens once training is complete and you and your training team are satisfied you have the skills.

Videos, booklets, information sheets, demonstrations and practice are some of the ways the team supports learning. Not only will you get to know all about the Home HD treatment and needling but you’ll also learn how to solve problems that may arise, and how to live a healthy lifestyle on Home HD. 

‘Home Haemodialysis – in training’  
This short video produced by the Princess Alexandra Hospital, Brisbane, presents a real-life example of training for Home HD. You can watch the video Home Haemodialysis - In Training here.

Getting supplies
The Home HD nurses will order your first dialysis supplies and they will be delivered to your home at a time to suit you. To store them, you’ll need a space about the size of a small wardrobe. The supplies are provided and delivered free of charge.

After the first delivery, you will be shown how to do a stocktake so you can keep a check that you have enough supplies. Usually a customer service person from the Home HD supply company will contact you to arrange a regular day and time when your ongoing supplies will be delivered. 

The first treatment at home
Home installation is a team effort involving the Home HD nurses, technicians and maybe a specialist electrician or plumber, and it’s usually organised in the days before you transfer to home.

Firstly, the team will prepare the electricity and water access for the machine in the room that’s been determined as suitable. The technician will then install, program and test the machine.

The nurses always supervise at least one or two treatments at home with you. It can feel very different doing Home HD in your home environment for the first time. It’s a good idea to plan a quiet week to allow yourself time to adapt to the routines. This investment of time will help you to cope better and focus while it’s all still new to you.

Getting support once you’re home
Once you are on Home HD you may need various types of support. This may be treatment-related or about travelling to training, carer assistance, or personal or financial. 

If you think Home HD is no longer the right option, you might want to consider centre-based dialysis, peritoneal dialysis or stopping dialysis. First you should explore all of your support options.

The criteria for eligibility for various types of support offered by the Commonwealth Home Program is set out here. For those who can pay for private nurses either, through Veterans Affairs or privately, this may also be an option.

Useful links
Talk to your Home Dialysis Clinic or social worker about local options in your State. You can find out more about other financial support here.

'Home haemodialysis  - going home' video
‘Home haemodialysis – going home’ shows what it’s like to do Home HD for the first time. It was produced by the Princess Alexandra Hospital in Brisbane, You can watch the video here.

Problem solving

Problem solving while on Home HD
As you’d expect with chronic kidney disease, treatment doesn’t always go perfectly. If you follow everything you’ve been taught, you’re far less likely to have problems, but some can arise. 

In managing these issues, there’s no substitute for advice from your dialysis healthcare team. Problem solving will be a key part of your training.

On the following pages we present a brief summary of problems that can occur if you’re on haemodialysis, regardless of where you do the dialysis.

Blood leak or spillage
Whether you dialyse at home or at a dialysis unit, the risk of blood leak or spillage is low. There are a number of ways to reduce this risk further, including:

  • securing the needles and lines safely
  • performing a safety check
  • using a blood leak detection device.

Low blood pressure
Low blood pressure can be caused by removal of too much fluid too quickly, or trying to remove too much fluid.

For some people this is never an issue, while for others it may happen more thanoccasionally. Dialysing the way you are taught, can reduce the risk.

Low blood pressure can also be prevented by doing more dialysis and drinking less.

If your blood pressure is dropping you will feel dizzy, have blurry vision, nausea, cramps, and you may faint. The treatment is to have some fluid, and you will be taught how to do this. With quick treatment your low blood pressure can be easily fixed. 

Vascular access infection
This is an infection in or around your fistula, graft or central venous catheter (CVC). For people on haemodialysis in Australia this happens on average once every three years, but is more likely if you have a CVC.

The infection occurs when bugs (bacteria) enter the access through the needle sites. It can be prevented by washing your hands and looking after your access site as you’ve been taught.

Like any skin infection, it will become red, swollen and you may have fever or pain. Infections can be treated with antibiotics and at the first sign it’s very important that you let your Home HD healthcare team know.

Many infections can be cured by antibiotics but some may require the CVC to be replaced. 

Blocked vascular access
This means that the blood flow through your fistula or graft has stopped. It’s usually caused by a blood clot in the vein. Some people never have this problem while others seem to be more prone.

The problem can be prevented by a using a good needling technique and avoiding bumps and bruising to the access site. It’s also important to ‘lock’ the CVC with prescribed medication after treatment.

You can often tell that the access is blocked when it’s difficult to put the needles in or the pressure alarms on the machine start to go off regularly. The buzzing feeling in the vascular access will stop and you may have swelling or pain.

The best response is to immediately go to hospital for a scan and de-clotting. Many blockages are easily fixed but if not you may need surgery or a temporary CVC.

Machine failure
Dialysis machines are like computers. Sometimes they fail because of a malfunction while at other times it’s because of ‘operator error’.

Problems can be minimised by training how to use the machine correctly and regular maintenance of the machine to help prevent malfunction.

If your dialysis machine fails, an alarm will sound that you cannot stop. You will need to contact a technician or your Home HD nurse as you have been taught.

The technician will repair or replace the machine. While this is happening you may need to attend a dialysis unit.

Useful resources
‘HHD - Benefits and concerns’
This informative video, produced by the Princess Alexandra Hospital in Brisbane, provides advice about problems that can occur with Home HD. You can watch this video here.

 

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