Gastroenterology and Renal

1

Nocturnal Home Hemodialysis

• Draft
• Claudia C. Ruiz-Zacharek, M.D.
• Medical Officer / Nephrologist

• Gastroenterology and Renal
• Devices Branch

2
Overview

• Background Information
• Nocturnal Home Hemodialysis
• Clinical Studies

3
Background Information

• Conventional Hemodialysis
• typically in-center, 4 hours 3 X week
• Patient has a passive role during treatment
• Nocturnal Home Hemodialysis
• performed at home, typically at night, and while
  the patient sleeps.
• Patient is the performer of the treatment

4
Data from the United States Renal Data System
(USRDS)

• Prevalence of patients on hemodialysis in the
  United States, 2002 281,594
• 0.3 (843) home hemodialysis patients
• 115 NHD patients in 13 centers in North America
• Lockridge, et. al., Adv Ren Replace Ther 2001
  8(4)250-256.

5
Definitions and Nomenclature

• Nocturnal Hemodialysis (NHD)
• Nightly Hemodialysis
• Nocturnal Home Hemodialysis
• In-center nocturnal hemodialysis,
• Long nocturnal hemodialysis
• Slow nocturnal hemodialysis, and
• Daily hemodialysis.

6
Definitions and Nomenclature (contd)

• Nocturnal Home Hemodialysis
• Performed at home
• Absence of medical personnel
• Frequency has reportedly ranged from 5-7 nights a
  week
• Length is 6-10 hours per night

7
Definitions and Nomenclature (contd)

• Nocturnal Home Hemodialysis
• Blood flows (QB) 200-300 ml/min,
• Dialysate flows (QD) usually 300 ml/min, up to
  800 ml/min
• Pierratos, A. Nephrol Dial Transplant 1999
  142835-2840

8
Definitions and Nomenclature (contd)

• Human factors
• Physician labeling
• Patient labeling
• Training

9
Definitions and Nomenclature (contd)

• Human Factors
• the objective is to improve human
• performance
• reduce the burden on training and labeling
• reduce the likelihood of use error and
• patient injury

10
Definitions and Nomenclature (contd)

• Human Factors
• The objective is to improve human
• performance
• Reduce the burden on training and
• labeling
• Reduce the likelihood of use error and
• patient injury

11
Definitions and Nomenclature (contd)

• Physicians Instructions for Use
• The manual that accompanies a medical device
• indications for use statement,
• contraindications,
• precautions and warnings.

12
Definitions and Nomenclature (contd)

• Physicians Instructions for Use
• The manual that accompanies a medical device
• indications for use statement,
• contraindications,
• precautions and warnings.
• It should also include relevant data from
  clinical studies and instructions for using and
  caring for the device.

13
Definitions and Nomenclature (contd)

• Patient Instructions for Use
• The manual that accompanies a medical device
• indications for use statement,
• contraindications,
• precautions and warnings.

14
Definitions and Nomenclature (contd)

• Patient Instructions for Use
• The manual that accompanies a medical device
• indications for use statement,
• contraindications,
• precautions and warnings.
• It should also include relevant data from
  clinical studies and instructions for using and
  caring for the device.

15
Definitions and Nomenclature (contd)

• Patient Instructions for Use
• The manual that accompanies a medical device
• indications for use statement,
• contraindications,
• precautions and warnings.
• It should also include relevant data from
  clinical studies and instructions for using and
  caring for the device.
• Written for a person with no medical training.

16
Definitions and Nomenclature (contd)

• Training
• Teaching provided by the manufacturer
• Medical expert to train the lay user
• Lay user to successfully use the device

17
Overview

• Background Information
• Nocturnal Home Hemodialysis
• Clinical Studies

18
Overview

• Background Information
• Nocturnal Home Hemodialysis
• Clinical Studies

19
Nocturnal Home Hemodialysis

• Device design and Components
• Human Factors Issues
• Water Quality
• Use of a Partner and Remote Monitoring
• Vascular Access and Extracorporeal Circuit
  Connections
• Labeling
• Lay-user Training

20
Nocturnal Home Hemodialysis

• Conventional Hemodialysis
• Patient is passive recipient

• Nocturnal Home Hemodialysis
• Patients active role
• Giver of treatment
• Presumably asleep
• troubleshooting

21
Nocturnal Home Hemodialysis

• Considerations for device design
• Redundancy
• Additional safety alarms may become necessary
• Loudness
• Sensitivity
• Ease of understanding and correction
• User friendly

22
Nocturnal Home Hemodialysis

• Consider the following additional safety
  features
• Safeguard to prevent blood access disconnections
  or air emboli
• Type of vascular access
• Alarms to detect fluid leaks
• Moisture detector
• Software to include remote monitoring
• User-friendly instructions
• Displayed screen with menus

23
Nocturnal Home Hemodialysis

• Human Factors Issues
• User-friendly
• Dispose of devices safely and effectively with
  minimal dangerous error
• Minimal dependance on labeling and training

24
Nocturnal Home Hemodialysis

• Water Quality concerns
• Conventional hemodialysis 360L/week
• Nocturnal Hemodialysis 648L-1080L/week
• Types of water treatment systems
• Reverse osmosis (RO)
• Deionization (DI)
• Combination

25
Nocturnal Home Hemodialysis

• Water Quality concerns
• Standard water quality for hemodialysis vs.
  higher standards
• Type of water treatment system
• Water source
• Municipal water suppliers
• Well water

26
Nocturnal Home Hemodialysis

• Issues on monitoring
• Without a partner
• In-center hemodialysis constant monitoring
• Home hemodialysis
• Raija, et.al. Experiences on Home Hemodialysis
  without an Assistant. Hemodialysis International
  2003 7(1)73-104.

27
Nocturnal Home Hemodialysis

• Issues on monitoring
• Monitoring is essential for the initial 3 months
  of nocturnal HD therapy until the HD team is
  convinced the patient is stable and compliant.
• The London Daily/Nocturnal Hemodialysis Study.
  AJKD, 2003

28
Nocturnal Home Hemodialysis

• Vascular access
• Arteriovenous fistula
• Synthetic graft
• Long-term cuffed catheter

29
Nocturnal Home Hemodialysis

• Vascular access
• Arteriovenous fistula
• Synthetic graft
• Long-term cuffed catheter

30
Nocturnal Home Hemodialysis

• Vascular access
• Arteriovenous fistula
• Synthetic graft
• Long-term cuffed catheter
• Quintaliani, et. al., Survival of vascular
  access during daily and three times a week
  hemodialysis. Clin Nephrol 2000 53372-377.

31
Nocturnal Home Hemodialysis

• Vascular access location
• Connection to the device
• Self cannulation
• Locking devices
• Enuresis alarms
• Moisture sensors
• Single vs dual needle technique

32
Nocturnal Home Hemodialysis

• Labeling
• Operators Manual
• Warnings
• Cautions and Precautions
• Device specifications
• Instructions for maintenance
• Cleaning and Disinfection
• Patient Labeling
• Physicians Labeling
• Additional risks

33
Nocturnal Home Hemodialysis

• Additional risks
• Inadvertent disconnections
• Blood loss from increased frequency of treatments
• Potential increased rate of vascular access
  infection
• Psychological effects

34
Nocturnal Home Hemodialysis

• Lay user training
• Conduct safe and effective NHD treatments
• Length of training reported to be approx 2-8
  weeks f
• Agar, et. al., Hemodialysis International 2003
  7(4)278-289.
• F Leitch, et. al., Am J Kidney Dis 2003
  42(1)S56-60.

35
Nocturnal Home Hemodialysis

• Lay-user training
• Appropriate use of the hemodialysis device
• Interpretation and use of safety features,
  accessories and hemodialysis treatment itself

36
Nocturnal Home Hemodialysis

• Lay-user training
• Water purification system
• Catheter lock boxes
• Moisture sensors
• Monitoring device
• Vascular access connection techniques
• Test the adequacy of the training

37
Overview

• Background Information
• Nocturnal Home Hemodialysis
• Clinical Studies

38
Overview

• Background Information
• Nocturnal Home Hemodialysis
• Clinical Studies

39
Clinical Studies

• Purpose
• Patient selection
• Study design

40
Clinical Studies

• Purpose
• To demonstrate the safety and effectiveness of
  the NHD devices under actual use conditions.

41
Clinical Studies

• FDA concerns
• Outcomes
• Clearance rates
• Findings
• Adverse events
• Training

42
Clinical Studies

• Reported patient selection
• Agar , et. al., Nocturnal Hemodialysis in
  Australia. Hemodialysis International 2003
  7(4)278-289.
• Alloatti, et. al., Long Nocturnal Dialysis.
  Blood Purif 2002 20525-530.
• Covic, et.al., Long-hours home haemodialysis
  the best renal replacement therapy method? Q J
  Med 1999 92251-260.

43
Clinical Studies

• FDA concerns
• Patient selection for trial
• Patient selection for marketing
• Patient performs the entire treatment
• Patient must wake up to attend the alarms

44
Clinical Studies

• Patient selection criteria
• Home environment
• Water supply
• Sewage
• Electricity
• Space
• Social interaction
• Patient's vascular access type and location
• Availability of a partner
• Patient's compliance
• Psychological well being

45
Clinical Studies

• Study design
• Control group
• Sample size
• Length of follow up
• Clinical endpoints
• Evaluation of outcomes
• Target patient population

46
Clinical Studies

• Other issues to be considered
• Dialysate composition and additives
• Type of anticoagulation
• Choice of dialyzer
• Type of monitoring
• Need of a partner
• Vascular access
• Reuse

47
Conclusion

• Nocturnal Home Hemodialysis Devices
• Safety is a primary concern
• Increased demands on patient and patients
  home/family should be assessed
• Treatment may only be available to a selected
  population
• Design of the clinical studies to demonstrate the
  safety and effectiveness of the device under
  actual use conditions should be discussed

48
References

• United States Renal Data System (USRDS)
  www.usrds.org
• Lockridge RS, Spencer M, Craft V, Pipkin M,
  Campbell D, McPhatter L, Albert J, Anderson H,
  Jennings F, and Barger T. Nocturnal Home
  Hemodialysis in North America. Adv Ren Replace
  Ther 2001 8(4)250-256.
• Pierratos, A. Nocturnal home haemodialysis an
  update on a 5-year experience. Nephrol Dial
  Transplant 1999 142835-2840
• Mehrabian S, Morgan D, Schlaeper C, Kortas C, and
  Lindsay RM. Equipment and water treatment
  considerations for the provision of quotidian
  home hemodialysis. Am J Kidney Dis 2003
  42S66-S70.
• Raija M, Riitta MK, Meeri K, and Eero H.
  Experiences on Home Hemodialysis without an
  Assistant. Hemodialysis International 2003
  7(1)73-104.

49
References

• Heidenheim AP, Leitch R, Kortas C and Lindsay RM.
  Patient Monitoring in the London Daily/Nocturnal
  Hemodialysis Study. Am J Kidney Dis 2003
  42S61-S65.
• Quintaliani G, Buoncristiani U, Fagugli R,
  Kuluiranu H, Ciao G, Rondini L, Lowenthal DT, and
  Reboldi G. Survival of vascular access during
  daily and three times a week hemodialysis. Clin
  Nephrol 2000 53372-377.
• Agar JWM, Somerville CA, Dwyer KM, Simmonds RE,
  Boddington JM, and Waldron CM. Nocturnal
  Hemodialysis in Australia. Hemodialysis
  International 2003 7(4)278-289.
• Leitch R, Ouwendyk M, Ferguson E, Clement L,
  Peters K, Heidenheim AP, and Lindsay RM. Nursing
  Issues Related to Patient Selection, Vascular
  Access, and Education in Quotidian Hemodialysis.
  Am J Kidney Dis 2003 42(1)S56-60.

50
References

• Alloatti S, Molino A, Manes M, Bonfant G, and
  Pellu V. Long Nocturnal Dialysis. Blood Purif
  2002 20525-530.
• Covic A, Goldsmith DJA, Venning MC, and Ackrill
  P. Long-hours home haemodialysis the best
  renal replacement therapy method? Q J Med 1999
  92251-260.
• The following articles have not been cited in the
  above discussion of NHD, but may provide
  additional information. Copies of these may also
  be found in Appendix F.
• Chan CT, Hanly P, Gabor J, Picton P, Pierratos A,
  and Floras JS. Nocturnal Hemodialysis Lowers
  Heart Rate during Sleep and Normalizes Its
  Parasympathetic and Sympathetic Modulation.
  Hemodialysis International 2003 7(1)73-104.

51
References

• Faratro R and Chan CT. Nocturnal Hemodialysis
  Improves Productivity of End-Stage Renal Failure
  Patients. Hemodialysis International, 2003
  7(1)73-104.
• Francoeur R and Digiambatista A. Technical
  Considerations for Short Daily Home Hemodialysis
  and Nocturnal Home Hemodialysis. Adv Ren Replace
  Ther 2001 8(4)268-272.
• Heidenheim AP, Muirhead N, Moist L, and Lindsay
  RM. Patient Quality of Life on Quotidian
  Hemodialysis. Am J Kidney Dis 2003 42S36-S41.
• Kjellstrand CM and Ing T. Daily Hemodialysis
  History and Revival of a Superior Dialysis
  Method. ASAIO Journal 1998 117-122.

52
References

• Kjellstrand CM and Blagg CR. Differences in
  Dialysis Practice are the Main Reasons for the
  High Mortality Rate in the United States compared
  to Japan. Hemodialysis International 2003
  7(1)67-71.
• Kroeker A, Clark WF, Heidenheim AP, Kuenzig L,
  Leitch R, Meyette M, Muirhead N, Ryan H, Welch R,
  White S, and Lindsay RM. An Operating Cost
  Comparison Between Conventional and Home
  Quotidian Hemodialysis. Am J Kidney Dis 2003
  42S49-S55.
• Lindsay RM, Leitch R, Heidenheim AP, and Kortas
  C. The London Daily/Nocturnal Hemodialysis Study
  Study Design, Morbidity, and Mortality Results.
  Am J Kidney Dis 2003 42(1)S5-S12.

53
References

• Lindsay RM, Alhejaili F, Nesrallah G, Leitch R,
  Clement L, Heidenheim AP, and Kortas C. Calcium
  and Phosphate Balance with Quotidian
  Hemodialysis. Am J Kidney Dis 2003 42,
  S1S24-29.
• Nesrallah G, Suri R, Moist L, Kortas C, and
  Lindsay RM. Volume Control and Blood Pressure
  Management in Patients Undergoing Quotidian
  Hemodialysis. Am J Kidney Dis 2003 42S13-17.
• Pierratos A. Daily nocturnal home hemodialysis.
  Kidney International 2004 651975-1986.
• Pierratos A. Quotidian Hemodialysis Is it the
  Solution to the Problem? Seminars in Dialysis
  2004 17(2)77-78.

54
References

• Radford MG, Shultman DS, Pasour AG, Cobb AM, and
  Chandler JT. An Incenter Nocturnal Hemodialysis
  Program Three Years Experience. Hemodialysis
  International 2003 7(1)73-104.
• Rao M, Muirhead N, Klarenbach S, Moist L, and
  Lindsay RM. Management of Anemia with Quotidian
  Hemodialysis. Am J Kidney Dis 2003 42S18-S23.
• Spanner E, Suri R, Heidenheim AP, and Lindsay RM.
  The Impact of Quotidian Hemodialysis on
  Nutrition. Am J Kidney Dis 2003 42(1)S30-S35.

55
References

• Suri R, Depner TA, Blake PG, Heidenheim AP, and
  Lindsay RM. Adequacy of Quotidian Hemodialysis.
  Am J Kidney Dis 2003 42S42-S48.
• Van Biesen W, Veys N, Vanholder R, and Lameire N.
  Effect of Long Nocturnal Dialysis on Nutritional
  Status and Blood Pressure Control. Hemodialysis
  International, 2003 7(1)73-104.
• Weick-Brady M. Medical Devices Going Home.
  FDLI Update 2003 September/October 23-24, 29-30.

56
References

• Weinger MB, Foreword to Designing Usability into
  Medical Products
• Woods JD, Port FK, Stannard D, Blagg CR, and Held
  PJ. Comparison of mortality with home
  hemodialysis and center hemodialysis A national
  study. Kidney International, 1996 491464-1470.
• Young BA, Hynes J, and McComb T. Home
  Hemodialysis Associations with Modality Failure.
  Hemodialysis International, 2003 773-104.