home hemodialysis patient manual - home dialysis …

The Home Hemodialysis Company © JVD Health Private Limited

HOME HEMODIALYSIS PATIENT MANUAL This document serves as the Home Hemodialysis Patient Guide – providing insight into Kidney Disease, Treatment options, Medication overview, Home Hemodialysis advantages and Implementation Plan.

Home Dialysis Patient Manual © JVD Health Pvt Ltd.

Contents 1. Kidney Function and Chronic Kidney Disease ........................................................................................... 5

1.1 Kidney Function .................................................................................................................................. 5

1.2 Chronic Kidney Disease (CKD) and its Symptoms ............................................................................... 5

2. Treatment Options .................................................................................................................................... 5

2.1 Hemodialysis (HD) ............................................................................................................................... 6

2.2 Peritoneal Dialysis (PD) ....................................................................................................................... 7

2.3 Kidney Transplant ............................................................................................................................... 8

3. Vascular Access For Hemodialysis (HD) .................................................................................................... 9

3.1 AV Fistula ............................................................................................................................................ 9

3.1.1 Caring for your AV Fistula and Vascular Access Graft ................................................................ 10

3.2 Central Venous Catheter ................................................................................................................... 10

3.2.1 Caring for your Central Venous Catheter ................................................................................... 10

4. Medication .............................................................................................................................................. 11

4.1 Phosphate Binders ............................................................................................................................ 11

4.2 Vitamin D........................................................................................................................................... 11

4.3 Iron Substitution ............................................................................................................................... 11

4.4 Erythropoietin ................................................................................................................................... 11

4.5 Anti-Hypertensives ............................................................................................................................ 11

5. Dietary Advice ......................................................................................................................................... 12

5.1 Protein ............................................................................................................................................... 12

5.2 Protein-Rich Foods ............................................................................................................................ 12

5.3 Calcium .............................................................................................................................................. 12

5.4 Sodium (salt) ..................................................................................................................................... 12

5.5 Potassium .......................................................................................................................................... 13

5.6 Phosphate ......................................................................................................................................... 13

5.7 Fluid Balance Control ........................................................................................................................ 13

6. Living with chronic kidney failure and dialysis ........................................................................................ 15

6.1 Exercise ............................................................................................................................................. 15

6.2 Driving ............................................................................................................................................... 15

The document is reference material only and has to be used in close consultation with the attending Nephrologist and the Home Hemodialysis Service Provider (THHC). This is not a Self-help Manual.


6.3 Smoking ............................................................................................................................................. 15

6.4 Work .................................................................................................................................................. 15

6.5 Sexual Relationships ......................................................................................................................... 15

6.6 Traveling ............................................................................................................................................ 16

7. Glossary ................................................................................................................................................... 17

8. Setting up my Assisted Home Hemodialysis ........................................................................................... 19

8.1 Introduction ...................................................................................................................................... 19

8.1.1 Referral ....................................................................................................................................... 19

8.1.2 Assessment ................................................................................................................................ 19

8.1.3 Treatment Options ..................................................................................................................... 19

8.2 Goals and Benefits ............................................................................................................................ 19

8.2.1 Benefits of Home Hemodialysis ................................................................................................. 20

8.3. Requirements ................................................................................................................................... 20

8.3.1 Age ............................................................................................................................................. 20

8.3.2 THHC Dialysis Technician ........................................................................................................... 20

8.3.3 Medical Criteria .......................................................................................................................... 20

8.3.4 Home Assessment and Renovations .......................................................................................... 20

8.3.5 Space .......................................................................................................................................... 21

8.3.6 Hemodialysis Access .................................................................................................................. 21

8.3.7 Supplies ...................................................................................................................................... 21

8.3.8 First Hemodialysis Treatment .................................................................................................... 21

8.3.9 Maintenance of Equipment ....................................................................................................... 21

8.3.10 Consent .................................................................................................................................... 21

8.4 Support .............................................................................................................................................. 22

8.4.1 Problem Solving ......................................................................................................................... 22

8.4.2 Follow-Up Visits ......................................................................................................................... 22

9. Treatment Options: Comparative Analysis ............................................................................................. 23

9. 1 Short daily HD pluses ....................................................................................................................... 23

9.2 Short daily HD minuses .................................................................................................................... 23

9.3 Who is best suited for short daily HD? ............................................................................................. 23

9.4 Compare the different types of dialysis ............................................................................................ 23

10. Home Hemodialysis Implementation Plan ........................................................................................... 25


10.1 Initial Set-up .................................................................................................................................... 25

10.1.1 Cost with options ..................................................................................................................... 25

10.1.2 Time-Frame and Process .......................................................................................................... 25

10.1.3 Patient’s Responsibility ........................................................................................................... 26

10.2 Operational Aspects ........................................................................................................................ 27

10.2.1 Per Session Cost Details ........................................................................................................... 27

10.3 Additional items .............................................................................................................................. 27

10.4 Home Hemodialysis - Management Best Practices ....................................................................... 27

10.5 Frequently Asked Questions ........................................................................................................... 28

Figures in this document

Figure 1: Inside a Kidney ............................................................................................................................... 5

Figure 2: Hemodialysis Treatment ................................................................................................................ 7

Figure 3: AV Fistula ....................................................................................................................................... 9

Figure 4: Typical Home Hemodialysis Set-up .............................................................................................. 26

Figure 5: Comparative Chart for Dialysis Options .......................................... Error! Bookmark not defined.


1. KIDNEY FUNCTION AND CHRONIC KIDNEY DISEASE

1.1 KIDNEY FUNCTION The kidneys are a pair of bean-shaped organs located at the back of the abdomen next to the abdominal

wall. Each is approximately the size of a fist. They are situated under the lower ribs, one on each side of

the spinal column. Kidneys are vital for the excretion of waste products from the body, the regulation of

the composition of body fluids and the production of some important hormones.

Waste Management Functions

Waste product removal

Excess fluid removal

Acid-base balance regulation

Electrolyte level regulation

Other Vital Functions

Blood pressure regulation

Regulation of red blood cell production

Regulation of calcium uptake

1.2 CHRONIC KIDNEY DISEASE (CKD)

AND ITS SYMPTOMS Kidney disease occurs when kidneys can no longer perform their functions due to diseases like Diabetes,

Blood Pressure, Glomerulonephritis, Cystic Kidney Disorders etc.. Permanently decreased kidney function

is referred to as Chronic Kidney Disease (CKD). Chronic renal failure/ Chronic Kidney Disease can be the

result of a gradual decrease in the efficiency of the kidneys over a long period of time. Sudden onset

kidney disorder is referred to as Acute Renal Failure/Acute Kidney Injury. This may have good recovery

potential.

In case of Chronic Kidney Failure, the kidneys are irreversibly damaged.

When the kidneys fail, the production of urine is reduced and the urine components i.e. water and waste

products, accumulate in the body and thereby result in a syndrome referred to as Uremia. Common

symptoms of uremia are fatigue, anorexia, nausea and itching skin.

The untreated kidney disorders can lead to severe medical consequences and even death.

2. TREATMENT OPTIONS There are three main types of treatment modalities:

Figure 1: Inside a kidney


Hemodialysis (HD)

Peritoneal dialysis (PD)

Kidney transplant

Some of these treatment options are only suitable for certain patients and not all treatments are available

at every treating hospital. Dialysis is a way of replacing the function of the kidneys; it cleans your blood

by getting rid of waste, extra salt and fluids and keeps the blood pressure and electrolytes, such as

potassium, sodium, calcium, phosphorus and chloride in balance.

The choice of best treatment option for you depends on number of factors like medical, social and

psychological, financial and insurance availability etc. Your doctor or THHC will help you in choosing the

most adequate treatment modality for you.

To become an educated and active patient, you should learn as much as possible about all treatment

options. Do consider your habits and lifestyle when choosing your optimal treatment option. Please do

not hesitate to consult your doctor or THHC about these issues.

2.1 HEMODIALYSIS (HD) This is a two-circuit system, in one circuit blood flows and in other one dialysate flows. The dialysate is

physiological fluid which has corrected composition of all body salts and water. These two circuits come

in contact with each other at dialyzer level. The dialyzer is two compartment system where blood is

separated from dialysate by semi permeable membrane. Across this membrane two basic principles of

physics work: one depending on concentration (Diffusion) and other is pressure dependent (Convection).

After passing through dialyzer blood is cleaned of impurities and extra water. The rate of removal of water

and impurities can be regulated by changing settings at Machine level. These are decided by your

physician and executed by your technician.

Hemodialysis uses a dialyzer (this is a special filter) to clean your blood.


Figure 2: Hemodialysis Treatment

The dialysis process is pain-free. Depending on the individual medical condition, patients usually have

three Hemodialysis sessions per week, each lasting on average between 4 and 5 hours. This amount of

time is necessary to sufficiently clean the blood, i.e. the longer the better.

Hemodialysis is the most common method used to treat chronic kidney failure. It is usually performed at

a dialysis center and can be performed at patients home. It requires a coordinated effort from the whole

THHC team, including your Nephrologist, dialysis technician/nurse, and dietitian. However, the most

important members of the complete healthcare team are you and your family. By learning about your

treatment, you can work together with your healthcare team (THHC) to achieve the best possible

treatment results and thereby improve your quality of life.

2.2 PERITONEAL DIALYSIS (PD) Peritoneal dialysis is another procedure for cleaning your blood which can be done at home or at work by

yourself. This treatment modality uses the lining of your abdominal cavity, to clean your blood. The

peritoneal dialysis solution flows through a tube into your abdominal cavity, where waste products and

excess water are filtered out of the blood through the peritoneum into the dialysis solution. The peritoneal

dialysis fluid is a sterile solution consisting of glucose and other electrolytes.

After several hours, when the dialysis solution is saturated with waste products from the blood, it gets

drained from your abdomen and is replaced by fresh solution in order to start the cleaning cycle again.

This cycle is repeated about four times a day and must be done carefully to avoid an infection, called

peritonitis.


Before you can start performing PD treatment, you need to undergo an operation where a soft tube (or

catheter) is permanently placed to your belly. This exit site serves the purpose of transporting the

peritoneal dialysis solution to and from your peritoneum. It takes approximately 10-21 days for the wound

to heal after the operation. The PD co-ordinator will train you how to use the PD system properly.

As PD is a treatment option which can be done at home, it is crucial that you have all the necessary

equipment and disposables available for performing the treatment appropriately. Therefore, dialysis fluid

and treatment disposables will be delivered to your home on a regular basis.

2.3 KIDNEY TRANSPLANT Kidney transplantation is a procedure where a healthy kidney from another person is implanted into your

body by surgery. The new kidney replaces the function of your own failing kidneys. New kidneys may come

from a live-related donor or deceased donor. For the success of the transplantation it is important that

the donor has a similar tissue type as the recipient. This is not absolute barrier. Currently with latest drugs

transplant is possible without matching of tissue or even blood group (For more details discuss with your

Nephrologist).

Kidney transplantation may offer you the highest quality of life. However transplant kidneys are scarce

and special medical requirements need to be met before a patient may undergo such a surgery. The

chance of your body accepting the new kidney depends on your age and medical condition.

Although a successful transplant can help return you to a good state of health, you will still need to take

medication daily and see your doctor regularly. For further information concerning transplant programs

and regimens please ask your Nephrologist.


3. VASCULAR ACCESS FOR HEMODIALYSIS (HD) Before starting your first HD treatment, an access to your bloodstream has to be prepared. This vascular

access allows your blood to be easily taken from a vein in order to flow through the bloodlines to the

dialyzer and back through bloodlines into the body. Therefore, such an access has to be surgically created

in the arm, leg or near the collarbone.

The three main types of vascular access for Hemodialysis are as follows:

AV fistula

Vascular graft

Central venous catheter.

3.1 AV FISTULA An Arteriovenous fistula (AV fistula) surgically joins your artery and vein. It is the treatment of choice for

chronic dialysis. When you first get a new AV fistula, it will take a few weeks or months to mature (i.e. to

heal and develop full functionality). Fistulas tend to last many years, longer than any other kind of vascular

access.

Figure 3: AV Fistula

If a patient’s veins are too small or weak for an AV fistula to be created, a synthetic graft (made from

synthetic material) may be used to form a connection between an artery and a vein. It is placed under the

skin like a natural vein. Compared with fistulas, grafts tend to have more problems with clotting or

infection and need replacement sooner, but a well cared for graft can last for years. The graft as well as

the AV fistula lies beneath the surface of the skin.


3.1.1 CARING FOR YOUR AV FISTULA AND VASCULAR ACCESS GRAFT

In order to avoid infections of your AV fistula and vascular access graft and to enhance their lifetime,

proper care of your access is vital. Therefore, the following guidelines should be observed:

Avoid having blood samples taken from the arm with the AV fistula (except during HD treatment

or with the THHC approval).

Check that the AV fistula is working every day as you have been shown by your healthcare team.

Avoid wearing tight clothing or a wristwatch on the vascular access arm.

Always wash your vascular access arm before each dialysis treatment. Therewith you can avoid

infections.

Highlight to THHC team immediately if you are worried that the AV fistula may not be working.

Avoid activities that might impair the blood flow to your AV fistula such as sleeping on the AV

fistula arm, carrying heavy shopping bags or having your blood pressure taken on the AV fistula

arm.

3.2 CENTRAL VENOUS CATHETER

A central venous catheter is a flexible tube placed into a central vein in the neck or chest or groin by a

dialysis physician. Sometimes it is not possible to wait until an AV fistula is ready before starting dialysis;

that is when a central venous catheter is needed.

Temporary catheters are being placed. Permanent catheters, intended for long-term use, may be held in

place by a special cuff under the skin and a few stitches. Catheters can clog, become infected, or cause

narrowing of the veins in which they are placed.

Catheter can be a helpful "bridge" while your fistula or graft is healing or can allow you to have dialysis

when other forms of vascular access are not available.

3.2.1 CARING FOR YOUR CENTRAL VENOUS CATHETER

As catheters are prone to infections, it is highly recommended that the following principles are

considered:

It is very important to always keep your catheter clean and dry. This means you must not swim,

shower or bath with the catheter.

Watch for signs of infection: redness, swelling, pain, high pulse or fever. Call your Nephrologist

right away if you notice any of these signs.

Never use scissors or other sharp objects near or around your catheter for any reason.


4. Medication If you need dialysis — your Nephrologist will prescribe various medications that serve various purposes

(e.g. promoting the production of red blood cells to prevent anemia). The most common medications are

described below.

4.1 Phosphate binders Phosphate is found in your dietary intake and is normally excreted by the kidney. In renal failure,

phosphate levels rise in your body. Together with other substances, this may lead to skin and eye

irritation. A further consequence is arteriosclerosis; i.e. calcification of the vessels which can lead to heart

disease.

As dialysis only helps to remove some but not all of the excess phosphate, phosphate levels in the body

have to be controlled additionally by restricting their intake orally (low phosphate diet) and by taking a

medicine called a phosphate binder.

Phosphate binders help to pass excess phosphate out of your body, reducing the amount of phosphate

that gets into your blood. These medicines "bind" the phosphate in your digestive tract by combining with

it to form a compound that is not absorbed into your blood.

4.2 Vitamin D Vitamin D is normally activated in the kidneys to help us absorb calcium from food, which is necessary to

keep our bones strong and healthy. People with kidney disease may be given vitamin D in an already

activated form, which helps the body absorb more calcium and thereby reduces the risk of bone disease.

4.3 Iron substitution Iron is a vital structural component of hemoglobin, a key protein found in normal red blood cells, which

transport oxygen. Without iron, anemic patients' bodies have difficulties replenishing adequately healthy

red blood cells and improving haematocrit levels.

Clinical management of iron deficiency involves treating patients with iron replacement products while

they undergo Hemodialysis. Iron is usually given by intravenous infusion at the time of dialysis.

4.4 Erythropoietin Erythropoietin, often referred to as EPO, is a hormone produced by the kidneys which stimulates the bone

marrow to produce red blood cells. As the production of erythropoietin in chronic kidney disease patients

is low, the level of red blood cells is reduced, which leads to renal anemia. Synthetic erythropoietin can

be given intravenously or through the skin as a substitute for natural erythropoietin in order to keep the

level of red blood cells stable.

4.5 Anti-hypertensives The kidneys are involved in controlling blood pressure and most patients with renal failure have high blood

pressure (hypertension). High blood pressure leads to heart disease and strokes. It is therefore very

important to control your blood pressure. There are several drugs that lower blood pressure and need to

be taken regularly.


5. Dietary advice Dietary advice differs according to the stage of kidney failure and the type of treatment given. Adequate

nutrition is very important and it should be an integral part of your treatment along with your dialysis and

medication. Please follow the dietary advice of your doctor or dietitian.

5.1 Protein Protein is needed for the repair and maintenance of body tissue, growth and for fighting infections. It is

also a vital component of body fluids, including blood. When on dialysis, you have to make sure that the

amount of protein in your diet is sufficient. Your dietitian will calculate the recommended amount of

protein intake and teach you about the right nutrition.

5.2 Protein-rich foods Fresh meat

Poultry (chicken and turkey)

Fish and other seafood

Eggs or egg whites

Small servings of dairy products

Compile a food diary or a list which includes your daily food intake and discuss this with your dietitian.

This will help to establish your protein intake and can result in further dietary advice.

5.3 Calcium Calcium is a mineral that is important for strong bones and, in combination with potassium, is needed for

healthy muscles and skeletal system. However, foods that are rich sources of calcium are also high in

phosphorus. To prevent the loss of calcium from your bones, you need to follow a low phosphorus diet

and take phosphate binders. To keep your calcium and phosphorus in balance and to prevent bone

disease, your doctor may prescribe a special form of vitamin D.

Only buy vitamin D recommended by your doctor or dietitian because you need a special form of this

vitamin. Do NOT take calcium supplements.

5.4 Sodium (salt) Salt is naturally found in most foods and is also used to add flavor to meals. Please always check the

ingredients of the food you buy to avoid eating hidden salt. Sodium controls the fluid balance in your

body; so restricting the intake of sodium (mostly from salt) becomes important to avoid fluid accumulation

if your production of urine has decreased.

Keep informed about your sodium restrictions

Keep an accurate food diary

Read the ingredients of your food

Limit the amount of processed and canned foods in your diet

Watch your beverage intake

Try using fresh herbs and other spices to flavor food instead of salt


Add a squeeze of lemon for intensive flavor

Be cautious when eating in restaurants

5.5 Potassium Potassium is a mineral that supports nerve and muscle function and is also found in food. It helps your

muscles and heart work properly. If your potassium level is too high (hyperkalemia) or too low

(hypokalemia), these organs can be affected. If your kidneys fail, you will probably need to limit your

intake of high-potassium foods. Your blood level of potassium will be checked regularly and your dietitian

will give you advice on a proper diet with the right amount of potassium.

Talk to your THHC dietitian or physician about creating an eating plan with the right balance of

potassium

Watch your diet. Limit foods that are high in potassium

Limit fruit and vegetables to the amounts recommended by your dietitian

Limit milk and milk products or replace with non-dairy substitutes recommended by your dietitian

Avoid fruit juices

Avoid salt substitutes and other seasonings that contain potassium

5.6 Phosphate Phosphate is a mineral found in all foods that is needed for the maintenance of healthy bones. However,

the body only needs a certain amount of phosphate. Our kidneys usually keep the balance right by

excreting phosphate whenever there is too much in the body. If your kidneys fail, you have to control the

levels of phosphate in your body by restricting your intake orally (low phosphate diet) and by using a

medicine called a phosphate binder that is taken with meals and snacks.

Reduce the amount of phosphate you eat

Take a medicine called a phosphate binder

Take the active form of vitamin D as prescribed

5.7 Fluid balance control One of the main functions of the kidney is to balance fluid in the body. In kidney failure, the most common

problem is that the body does not get rid of the excess fluid, a condition called fluid overload. In its

extreme form, fluid will settle in the lungs, causing pulmonary edema and shortness of breath. The goal

of treatment is to achieve a fluid balance that is close to normal. The weight after dialysis, in which the

excess fluid is removed and the normal fluid balance is achieved, is called "dry weight."

The fluid allowance for each patient is determined by the amount of urine produced in a 24-hour period.

Most people are limited to 700-1000 ml of fluid per day plus urine output. Fluid allowances vary from

person to person and also depend on how much residual kidney function is left and on the individual's

body size. Weight gain should not exceed 1-1.5 kg within one dialysis-free day, and 1.5 - 2.5 kg over 2-3

days. If large amounts of fluid need to be removed during dialysis it can make you feel ill; your blood

pressure may fall and you might feel light-headed or sick.


Avoid salty and spicy food

Be aware of hidden fluids in foods (gelatin, watermelon, soup, gravy and ice cream)

Stay cool. Keeping cool will help reduce your thirst, especially in warmer weather. Try drinking

cold liquids instead of hot beverages

Sip your beverages. Sipping will let you savor the liquid longer. Use small cups or glasses

Try ice. Many patients find that ice is more satisfying than liquids

Battle dry mouth. Dry mouth can be uncomfortable. Instead of drinking fluid to refresh your

mouth, try using mouthwash or brushing your teeth. Sucking on hard candy or a wedge of lemon

or lime will also help.


6. Living with chronic kidney failure and dialysis Adapting to dialysis can be difficult at times; it is also normal that you will have fears about living with

chronic kidney failure. Dialysis is not problem free but it affords you the chance of a good quality of life.

Please discuss all issues with your Nephrologist; this can be helpful in dealing with your feelings for you

and your family. Being a dialysis patient does not imply that you are unable to work or join your leisure

activities. A good support system of medical staff, friends and family will help you cope with the new

adjustments you face.

6.1 Exercise Your general health will benefit from regular exercise. Many people with chronic kidney disease say

exercise was the key to helping them feel "normal" again after they started dialysis treatments. Before

beginning any exercise program, please consult your doctor for approval and so that he can determine

the "right" kind of exercise for you. The exercise program should meet your special needs and interests.

Learn how exercise can help you feel better physically and be more in control of your emotions.

6.2 Driving Kidney failure in itself does not affect your ability to drive. If you have heart disease, eye trouble or do not

feel well after the treatment, please ask your physician for advice.

6.3 Smoking While we are all familiar with the health risks smoking has on the lungs and heart, studies have shown

that smoking also aggravates kidney disease. Smoking is a burden on your blood vessels and heart. On

dialysis, you should quit smoking. Whether you are in the early stages of kidney disease or are on dialysis,

your physician will discuss with you the different ways to help you stop smoking.

6.4 Work Many patients with chronic kidney disease (CKD) are in full-time or part-time jobs. With your doctor’s

permission and an open discussion with your employer about all relating issues, you will be able to

continue your work. Your doctor will try to schedule your treatment conveniently; please discuss details

with your THHC team.

6.5 Sexual relationships Sexuality does not only mean the act of sexual intercourse, it also includes feelings, communication and

how willing you are to build a relationship. Physical and emotional changes caused by your disease may

affect your sexuality. Kidney disease can cause physical and emotional changes that may lower your sexual

interest and/or sexual ability.

People with end stage renal disease may feel tired after their haemodialysis treatment. Ongoing fatigue

should be discussed with your doctor and renal dietitian. Men with renal disease may experience changes

in their hormone levels that affect their sexual interest. Please discuss this issue with your doctor so that

he can get the right help for you.


6.6 Traveling Everybody needs a break from time to time, and kidney patients are no exception. However, traveling for

kidney patients on dialysis does require more planning, so last minute bookings are not a realistic option.

Please ask the THHC staff to assist you with the planning process and to help make sure you have a nice

holiday. THHC will help you arrange holiday dialysis treatments in different countries.


7. Glossary Acute Renal Railure – is the sudden and temporary loss of kidney function. Acute renal failure can be

caused by diminished blood supply to the kidneys, obstructed urine flow or traumatic damage to the

kidneys caused by, for example, major surgery or a car crash. Acute renal failure is treated with continuous

renal replacement therapy, usually at the intensive care unit in a hospital.

Arteriovenous (AV) Fistula - is a blood vessel that is made by surgically sewing together an artery and a

vein (often in the forearm) to create the rapid blood flow needed for efficient haemodialysis treatment.

It is also commonly called a native fistula.

Blood Pressure - is the pressure exerted by the blood against the walls of the blood vessels, especially the

arteries. Too high blood pressure increases the risk of heart attack and stroke and is treated by blood

pressure medication (antihypertensives).

Catheter - is a flexible plastic tube for insertion into a body cavity used to allow the passage of fluids.

Chronic Kidney Disease – is the slow and progressive loss of kidney function over several years, resulting

in permanent kidney failure. People with permanent kidney failure need dialysis or a kidney transplant to

replace the work of the diseased kidneys.

Chronic Kidney Failure - means less than 10% of kidney function.

Creatinine – is a breakdown product of creatine phosphate in your muscles. Your physician can test your

creatinine clearance and check how efficiently the kidneys remove creatinine. Low creatinine clearance

indicates impaired kidney function.

Diabetes - is a disease in which abnormal carbohydrate metabolism causes high glucose levels and can

lead to kidney failure. About 20% of all patients with diabetes develop kidney failure.

Dialysis Fluid – constitutes a mixture of water, glucose and electrolytes used in dialysis to fulfill the body's

needs. Dialysis fluid usually contains sodium, magnesium, chloride, potassium and calcium. During

dialysis, waste products in the blood pass through the semipermeable membrane of the dialyzer into the

dialysis fluid.

Dialysis Treatment – is an artificial medical treatment process by which the toxic waste products and

water are removed from a patient’s body.

Dialyzer - is the filtering unit of a dialysis machine. The dialyzer removes waste products and excess water

from the blood.

Dwell Time – is length of time peritoneal dialysis patients keep fresh dialysate in the abdomen. After the

dwell time is over, the used dialysate is replaced with fresh dialysate either by the patient themselves or

by a cycler machine.

EPO - is a commonly used abbreviation for erythropoietin.


Erythropoietin – is a hormone produced by healthy kidneys that tells the bone marrow to produce

erythrocytes (red blood cells). Synthetic hormone versions are available for kidney patients. Lack of this

hormone may lead to renal anemia.

Haemoglobin - is the substance in erythrocytes which carries oxygen around the body. The iron contained

in haemoglobin is responsible for the red color of the blood. A decreased level of haemoglobin is known

as anemia. Anemia causes tiredness, shortness of breath and paleness.

Immunosuppressive Drugs – are drugs used to make the immune system less effective, so that a

transplanted kidney will not be rejected.

Kidney Transplant – means replacement of a diseased kidney with a healthy one. A kidney transplant may

come from a living donor, usually a relative, or from someone who just died.

Standalone Haemodialysis Centre – is a centre that is located away from the main hospital dialysis centre.

The Dialysis Centre - is the place where a team of healthcare professionals treat kidney patients who need

dialysis.

THHC (The Home Hemodialysis Company) - Your Health Service Provider.

Ultrafiltration - means the removal of excess water from the blood.

Urea - is a waste product found in the blood and caused by the normal breakdown of protein in the liver.

Urea is normally removed from the blood by the kidneys and then excreted in the urine. Urea accumulates

in the body of people with kidney failure and tells us the level of kidney function.

Vascular Access – is a method of gaining entry to the bloodstream so that dialysis can be performed. AV

fistula is one form of access for haemodialysis.

Vascular Access Graft - is an access that is made by connecting one end of a piece of artificial vein to the

patient's vein and the other end to the patient's artery. The graft is a larger vessel that allows the rapid

blood flow needed for efficient haemodialysis. It is commonly called a graft. Avoid wearing tight clothing

or a wristwatch on the vascular access arm. Always wash your vascular access arm before each dialysis

treatment just as your healthcare team has taught you. Therewith you can avoid infections. Consult the

dialysis centre immediately if you are worried that the AV fistula may not be working. Avoid activities that

might impair the blood flow to your AV fistula such as sleeping on the AV fistula arm, carrying heavy

shopping bags or having your blood pressure taken on the AV fistula arm.


8. Setting up my Assisted Home Hemodialysis

8.1 Introduction The home Hemodialysis program has been offered world-wide to kidney patients and their families for

many years. Home Hemodialysis gives you greater independence. The Trained technician from THHC shall

be visiting your home for performing the Hemodialysis. This freedom allows you to schedule your own

treatment time, stay at home and be actively involved in all aspects of your care. It gives you freedom and

flexibility.

8.1.1 Referral

You may be referred to learn more about home Hemodialysis by:

A Nephrologist

Fellow Patient

You! - After seeing our poster, pamphlet or word of mouth

8.1.2 Assessment

An assessment session will be required prior to setting up and starting Home Hemodialysis. You and your

family should attend together. There will be a home hemodialysis physician, dialysis technician and THHC

staff available to explain the entire process of home Hemodialysis in detail, and answer any questions or

concerns you may have.

8.1.3 Treatment Options

The following treatment options are prescribed based on your dialysis requirements:

Type Duration

Short Daily HD 2 -3 Hours

Conventional HD 4 Hours

Nocturnal (nightly) HD 7-8 Hours

You should discuss these options with your Nephrologists & THHC to identify the best possible

frequency/option. THHC will accordingly plan the session implementation in terms of adequate support

from the Dialysis Technician and the session supplies.

8.2 Goals and Benefits The Home Hemodialysis Company will:

Provide information to you about home Hemodialysis

Support you in a familiar and comfortable environment

Provide technical support for your water treatment cart and dialysis machine

Support you with regular telephone contact and an on-call system

Follow-up care by nurses, technicians and home hemodialysis physicians


You will:

Ensure that all prescribed Dialysis sessions are conducted by the THHC Technician

Be actively involved in all aspects of your care

Demonstrate a good understanding of hemodialysis in all aspects

Attend regular scheduled doctor appointments

Allow technicians into your home for regular visits and equipment maintenance

8.2.1 Benefits of Home Hemodialysis

• Independence with your hemodialysis treatment

• Increased well being. Quality - get more dialysis to feel better

• No travel time to hemodialysis treatments

• Flexible treatment schedule to fit your lifestyle

• Greater knowledge and understanding of your disease process and health status

• Gives your family the opportunity to be involved with your care

• Control - eat, drink, and have visitors during treatments

• Longer life - survival may be about the same as deceased donor transplant (3 times better

than standard in-center HD)

8.3. Requirements

8.3.1 Age

There is no age restriction.

8.3.2 THHC Dialysis Technician

An experienced Technician will perform your dialysis treatments at home, as per the industry standard

Dialysis procedures/stipulations.

8.3.3 Medical Criteria

During your assessment you will meet the home hemodialysis physician who will assess your physical and

mental suitability as well as your hemodialysis stability prior to being accepted into the program.

8.3.4 Home Assessment and Renovations

The THHC staff will visit and assess your home to determine what renovations need to be completed.

The purpose of the visit is to:

Assist you in choosing a suitable location for the dialysis machine, the water treatment equipment

and (optionally) the dialyser re-use equipment.

Determine what plumbing changes are necessary for your treated water.

Assess the need for a water sample.

Pick the location for electrical outlets for the equipment.


Later, THHC will work with you and your family how to:

Set up a treatment room

Run and care for the dialysis machine

Store and order your supplies

Keep treatment logs

Take your blood pressure

Follow your diet and fluid limits

Recognize and report any problems

The dialysis technician will be help with most of these tasks.

8.3.5 Space

You must have adequate space in your home to accommodate the dialysis machine, water treatment

equipment and supplies. Space is needed for one month of supplies at a time. Please refer to Section

10.1.3 Patient’s Responsibility for specific details.

8.3.6 Hemodialysis Access

You need a good blood supply from your fistula, graft or central venous catheter (CVC) to initiate home

hemodialysis.

8.3.7 Supplies

There will be an initial supply delivery before initiating the home hemodialysis. The THHC will provide

your supplies on a regular basis once a month, as instructed during your orientation period.

8.3.8 First Hemodialysis Treatment

Arrangements will be made by the technicians to go out to your home and set up the dialysis machine

and the RO water equipment prior to your initial dialysis run at home to make sure the equipment is

running properly. Your dialysis technician will be performing the home dialysis treatment.

8.3.9 Maintenance of Equipment

If you should be on vacation or have a stay in hospital, long periods of equipment non-use will require

cleaning procedures to prevent bacterial growth. It is recommended to continue with regular weekly

disinfection of water treatment and dialysis machine; this task could be taken up by the dialysis

Technician. You need to contact THHC for further information about maintenance if you are away for an

extended period of time.

8.3.10 Consent

At the start of the home dialysis treatment plan you must sign a consent form. This indicates that you

agree to undergo Home Hemodialysis according to standards of care outlined below:

You must undergo hemodialysis as by your home hemodialysis physician

You must do your monthly blood work as scheduled

You must order supplies as scheduled

You must attend regular clinic appointments


You must communicate to the THHC any problems that occur with access, equipment or

treatment

You must assist in completion of all documentation required such as dialysis data records and

service log sheets

You must facilitate maintenance of your equipment as prescribed

8.4 Support

8.4.1 Problem Solving

During your orientation you will be you will be made aware of the alarms and common dialysis related

problems. The dialysis technician will be able to address most of the issues/scenarios.

THHC will provide a list of Ambulance Service Providers that can be used to ensure Patient relocation to a

medical facility, to address any exigency.

8.4.2 Follow-Up Visits

Depending on where you live and how you are doing, follow-up visits will be every month. At clinic you

will see a dietitian, clinical psychologist and the Nephrologist. You are required to bring dialysis data

records to clinic and may be advised ahead of time of yearly checks such as fasting blood work,

echocardiograms or bone densities. Fistula checks will be done every 3 – 4 months.

8.4.3 Labrotary Services

THHC will provide a list of preferred laboratory service provider(s) to be engaged for investigations. The

patient samples would be collected by the THHC technician/lab technician during session or as required

frequency. The standard sample collection frequency is as detailed below:

Test/Investigation Frequency

CBC, KFT, LFT, Urine RE, HBsAG, HCV, HIV, iPTH, Lipid Profile, HBA1C, HB Count, Iron studies (S.Iron & TIBC), S. Ferritin, Anti HBS Micro Gluoblin, TSH, USG Abdomen, X-ray chest PA View, Echocardiography

At the Start of the HHD

Hemogram, KFT, LFT, Urine R/E Monthly

iPTH, Lipid Profile, HB Count, Diabetic Patient-Iron studies (S. Iron & TIBC), S. Ferritin

3 monthly repetition


9. Treatment Options: Comparative Analysis

9. 1 Short daily HD pluses

You can choose your own treatment days and times—and shorter treatments are easier to fit into

your life. Short daily HD is a work-friendly treatment.

With more frequent treatments, people feel much better and have more energy.

You’ll have fewer (or no) diet and fluid limits with more treatment.

Since you (or a partner) are the only ones putting needles in your access, it is likely to last longer

with fewer problems or trips to the hospital.

You can follow your own house rules for eating, drinking, or visitors during treatments.

You’ll save time not having to drive to and from the clinic three times a week.

You can do short daily HD while you travel.

Short daily HD controls blood pressure very well, which can help protect your heart from damage.

Studies have found that people who do short daily HD may live about as long as those who get a

kidney transplant from a deceased donor. This is about three times longer than standard in-center

HD.

Research shows that the more you know about your treatment and the more you do for yourself,

the longer you are likely to live.

9.2 Short daily HD minuses Needing a partner to be there for each treatment can strain your relationship, or cost you money

to hire someone. (NOTE: Strong relationships tend to get stronger with home HD.)

Training can take a few weeks, and you may need to take time off work to do it.

You’ll need room to store the machine and supplies, and time to set up the machine, clean it, and

order what you need.

You and a partner will need to learn to keep your cool and deal with problems that may arise.

Two needle sticks are needed for each treatment, and you (or your partner) will need to learn to

place them. (You can use medication to numb the sites so it doesn’t hurt.)

Short daily HD takes a few hours out of your day each day you do treatments.

9.3 Who is best suited for short daily HD? The most important factor in whether you are suited for short daily HD is how much you want to do it. As

long as you or a partner can pass the training and learn to place your needles, you should be able to

succeed. Each program that offers short daily home HD has its own screening methods to be sure that

people understand what they are getting into and are willing to commit to the training and the treatment.

9.4 Compare the different types of dialysis The following chart depicts the pluses and minuses for each of the dialysis types and in-center

hemodialysis to help you weigh-in your options.

http://homedialysis.org/article/life_at_home/keeping_your_job_when_you_need_dialysis

http://homedialysis.org/article/life_at_home/lvh_heading_off_a_common_heart_problem


Table 1: Dialysis Treatments - Comparative Analysis

Variable with outcome CAPD Home Hemodialysis

In Centre Hemodialysis

More Normal Diet & Fluids

More dialysis to feel better

Work-friendly treatment

Puts you in charge

You’re not around sick people

Portable – take it with you

Flexible – suits your schedule

Needle-free treatments

Have your days free

Medicine requirements

Need to visit clinic 3 times a week

Supply storage space needed

Infection risk

Weight gain from dialysate

Limits swimming, tub bathing

Privacy

A partner is needed


Legend:

CAPD: Continuous Ambulatory Peritonial Dialysis, CCPD: Continuous Cycler PD, HHD: Home

Hemodialysis, DHHD: Daily HHD, NHHD: Nocturnal HHD, IHD: In-Center HD

10. Home Hemodialysis Implementation Plan The following sections provide details on the following key elements of starting and maintaining the Home

Hemodialysis procedure at Patient premises:

a. Initial Set-up

Cost with options

Time-frame and process

b. Session specific parameters

Cost with available options

Procedure

c. Medical records Management

d. Patient follow-up and medial management procedure

10.1 Initial Set-up

10.1.1 Treatment Options

THHC shall provide the Home Hemodialysis (HHD) set-up at the Patient premises / home location. There

will be following options available for creating the set-up:

a. Plan with a Dialyser Re-use equipment

b. Plan without Dialyser Re-use equipment

The set-up will include Hemodialysis Machine, RO equipment, Dialysis Chair, Dialyser Re-use equipment

(optional) and other supporting items. AMC charges for respective equipment(s) will be borne by the

Patient.

10.1.2 Time-Frame and Process

Timeframe to create the set-up is about 25 working days from the day the agreement to initiate HHD is

signed-up.

Time-frame/Milestone Set-up Item/activity

Day 0 Sign-ing up the HHD agreement/Consent/payments

Day 2-3 Final site due diligence (for readiness) Identify the room/placements in the home location

Day 5-10 Installation of RO Unit / Machine installation/reuse

Day10-25 Orientation for the Patient, Family Members,technical staff

Day 25 End to End Delivery Procedure Check

Day 25 First Home Dialysis Session Table 2: Initial set-up Time-frame/milestones


10.1.3 Patient’s Responsibility

For the initial set-up the following infrastructure elements/components shall be required to be

provisioned by the Patient at the premises, where the HDD set-up needs to be created.

Figure 4: Typical Home Hemodialysis Set-up

Sno Set-up Item Dimensions Power Requirement

Other Specifications

1 Room 12’x 14’ Well ventilated

2 RO Unit Space 4’x4’ 15 A Input : Running/Stored MCD Water Connection

3 Air-conditioning Unit

15 A 1.5 Tons

4 Dialyser Re-use equipment Space

4’x4’ 80W

5 Dialysis Machine

4’x4’ 5 A Has 20 minutes in-built battery back-up. The machine will be hosted adjacent to the Dialysis Chair

6 Attached Wash Room

Preferred, Not mandatory

7 Power Back-up / UPS

8 Dialysis Session Inventory Storage

5’x3’x2’ NA Typically, a standard almirah with 3-4 shelves will suffice.

Table 3: Home Set-up Space / Power Requirements


10.2 Operational Aspects

10.2.1 Per Session Cost Details

Option # Dialysis Option Definition/Description Per Session Cost

1 LF Low Flux – No Reuse 5000

2 LF + BB Low Flux , BiBag 5500

3 LF / R Low Flux with Dialyser Re-use 4000

4 HF High Flux – No Reuse 5500

6 HF + BB High Flux , BiBag 6000

7 HF / R High Flux with Dialyser Re-use 4000 Table 4: Home Dialysis Options - Per Session Cost

10.3 Additional Items THHC shall address the following aspects for the Home Hemodialysis Patients:

1. Patient Review

2. Technician availability

3. Medical waste management

The Patient shall facilitate the following aspects related to the Home Hemodialysis.

1. Laundry Management

2. House-keeping for the Dialysis Room

3. Electricity and water expenses (includes UPS facility)

4. Adequate Air-conditioning for the Dialysis room

5. Ensuring cleanliness around the RO Water Treatment and Dialyzer Reuse equipment

10.4 Home Hemodialysis - Management Best Practices THHC technician will be maintaining a dialysis session log. This log/data will be available to the attending

Nephrologist and THHC staff for follow-up actions/review.

In addition, the following measures are prescribed for effectively managing the home hemodialysis

treatment plan.

Key Patient Health Measures Frequency

URR Monthly

Kt/V Monthly

Key RO Water Quality Measures

Equipment/set-up Physical examination Quarterly

Conductivity

Monthly

Bacterial / Viral Colonization Status/AMMI Quarterly Table 5: Follow-up procedures/measurements


10.5 Frequently Asked Questions

Q1. Why Should I change my current treatment (in-Center Hemodialysis) modality? Cost is not important

for me and I live near to the HD center, but quality is very important for me.

The benefits of Home Hemodialysis are detailed in the preceding chapters (refer Section 8.2.1 Benefits of

Home Hemodialysis). There are specific medical studies/research findings that provide data on the

positive results experienced by individuals on Home Hemodialysis.

Q2. What all can go wrong during the Home Hemodialysis Session, what are the solutions/alternative s

that exist for me?

The reaction/process in-case of the exigencies shall be same as in a large (hospital) set-up, except that

transition time latency shall be there regarding movement to a Critical care set-up (ICU). The ambulance

service shall transport the patient to nearest Hospital set-up. For instance, Tubing bursts (unlikely, for

example sake though), immediately the blood flow shall be stopped by the technician, machine stopped

and the tubing replaced, session re-initiated.

There would be a list of Emergency Patient Movement / Ambulance Services options provided to the

patient. He/she can pick the nearest/optimal (reaction time, cost) vendor. Service provider will identify a

preferred Ambulance Service Provider for the Patient.

Q3. What is the impact of Water Quality on the treatment, how will this be ensured.

The blood cleansing during the Hemodialysis treatment depends on the quality of water. Good quality of

water based on the custom developed RO treatment plant installed by THHC will ensure Ultra-pure water

quality. This will ensure dialysis treatment will be comparable to best available.

Q4. What is frequency of the HD sessions, Duration?

It is suggested that a 3 hours session for 5 days a week or 6 hours nocturnal 3 times a week, be adopted

for best / optimal results. This assessment shall be finalized by working closely with the Nephrologist.

Q5. What is the Cost of these sessions?

Per session cost primarily is dependent on 02 factors:

a. Type of Dialyser

b. Reuse Plan

Details in terms of rupee cost per option are described in Section 10.2.1 Per Session Cost Details.


Q6. Can I come back to my earlier mode of dialysis? What will happen to the equipment that I would have

paid for?

Yes. The changes in treatment modalities can be planned after discussions with THHC.

The following options shall be available:

Equipment Covered Time Period (Months from Installation)

Buy back Cost (% of initial paid-up cost)

1. Dialysis Machine 2. Dialyser Re-use

equipment

6 – 18 50

18 – 36 30

Q7. What is the space requirement?

Optimal space requirement is for 225 sq feet of space to host the Dialysis Machine, Dialysis chair , RO

equipment and Dialyser Re-use equipment. The detailed space break-up is presented in Section 10.1.3

Patient’s Responsibility.

Q8. What will happen if the water from the Overhead Tank is hot (for instance: during Summer in India).

For each installation location, during the initial site inspection/assessment visit/follow-ups, the water

treatment experts in the THHC come up with optimal solutions for varying operating conditions.

While specific opinion will be sought and implemented to ensure best possible solution as a general

implementation specification, it is observed that due to water passage time/process via the RO equipment

the water temperature drops to 37 degrees centigrade with acceptable level for Dialysis Machine

operations.

Q9. I am keen to use the High Flux Dialyser, will this be possible?

As a standard specification, THHC recommends initiation on Home Hemodialysis to be with Low Flux

dialysis. After adequate assessments are completed for Water quality in the Patient premises (typically,

home location) over a 03 months period to ensure consistent Ultrapure criterion is met; the High Flux

Dialysis sessions are initiated.

Q10. I want to travel out of the city / country, what will happen to my treatment in those scenarios?

Once you are associated with THHC, we would work towards facilitating dialysis as per your travel

itinerary. This is worked out per availability of In-Center Dialysis treatment at your destination or in

vicinity. We would strive to get you the local contacts/address and appropriate appointments (date/time

slots). Given that these will be centers out of direct jurisdiction / scope of THHC, the Quality, Care and

Costs of treatment at these centers will as per local administration/management. As a best practice; THHC

recommends testing of HBsAg, HCV and HIV serology, within 02 weeks of your return.

Q11. How will this impact Quality of my Life?


Time; both in terms of selecting the time-slot for your treatment & increased ability to spend quality time

with the family, is a major contributing factor. Also, more frequent & planned HD sessions ensure better

treatment delivery (also, refer response to Q1).

Q12. How would the availability of the Technician be guaranteed?

THHC will co-ordinate the technician availability as per your requirements. For effective implementation,

per Month plan shall be prepared and shared 07 days in advance. In case the scheduled Technician is not

available due to unavoidable circumstances; an alternate Technician shall be facilitated.

Q13. Will there be any bio-waste, how will this be managed?

THCC shall facilitate collection of bio-waste directly from your premises.

Q14. Who would manage the supply of consumables - things required for performing Hemodialysis.

A weekly inventory shall be shipped to your location. Each shipment will have a day-wise package. It is

recommended to order the weekly inventory, at-least 7 days in advance.

Q15. Will there be a doctor available during the Session?

No. Your Nephrologist will be the one to be consulted for any queries/follow-ups.

At the end of the session, the Technician will file the Session Report. This will help identify any issues /

unexpected observations during the session. THHC will help address these with appropriate response.

Q16. Will I be required to change my doctor?

No. You would continue to remain under care of your existing Nephrologist. THHC will provide information

about you to your Nephrologist.

Q17. What will be the frequency of Dialysis, can this be done at night?

The frequency of dialysis shall be as per recommendations of your Nephrologist. It can be standard 12

hours per week dialysis regimen or for better outcome – further increased time duration.

Q18. Are these going to be new machines? What will happen to the set-up, machines incase I want to

change

Yes, these shall be new machines with certificate of being unused. Incase you are seeking Used/re-

furbished machines, these can also be facilitated. THHC will have a list of recommended machines.

Q19. What is the Maintenance Plan for the machines (AMC etc.)?

The individual equipment will have respective AMC costs, to be borne by the patients. THHC will facilitate

follow-ups.

Q20. How will the tests be done, can the samples be collected by the technician, during the session?


THHC has specific tie-ups with labs, the list of labs will be provided at the treatment initiation. The

technician will collect samples before/after session, as required.

Q21. Whom do I contact for more information?

THHC can be contacted for further clarifications at the following address:

29 LGF, Pocket B, Jasola Vihar (Near DDA Sports Complex), New Delhi.

CAPD CCPD HHD DHHD NHHD IHD

More Normal Diet & Fluids

More dialysis to feel better

Work-friendly treatment

Puts you in charge

You’re not around sick people

Portable – take it with you

Flexible – suits your schedule

Needle-free treatments

Have your days free

Medicine requirements

Need to visit clinic 3 times a week

Supply storage space needed

Infection risk

Weight gain from dialysate

Limits swimming, tub bathing


Privacy

A partner is needed

home hemodialysis patient manual - home dialysis …

Documents