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  • Review Article
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Home haemodialysis and uraemic toxin removal: does a happy marriage exist?

Nature Reviews Nephrology volume 8, pages 579–588 (2012)Cite this article

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Abstract

Home-based methods of haemodialysis are becoming of increasing interest. In this article, we review theoretical and evidence-based aspects of dialysis adequacy in the home setting compared with those of standard in-centre dialysis. Owing to the flexibility it enables, home haemodialysis may allow reduced blood flow rates and the successful use of less-efficient access systems. With home haemodialysis, Kt/Vurea targets should be pursued as recommended in current guidelines, taking into account that this parameter does not reflect a number of essential elements that affect adequacy, such as dialyser pore size or alternative timeframes—factors that might be applicable to modern home haemodialysis. The use of high-flux, large-pore haemodialysers is associated with improved removal of large uremic toxins and should be considered as standard in home haemodialysis where possible, although dialysis water purity is crucial. Large molecule removal is further enhanced by applying convective strategies (such as haemo[dia]filtration), but these strategies greatly increase technical complexity. Alternate-day haemodialysis is more desirable than the usual thrice-weekly approach to avoid complications at the end of the long weekend interval, and it is easier to implement such a regime at home than in-centre. Frequent, prolonged, and combined frequent and prolonged dialysis regimes are all associated with improved removal and improved outcomes. All three alternative timeframes are easier to apply at home than in-centre. Home haemodialysis offers increased flexibility in adopting dialysis regimes that make it possible to improve solute removal and, therefore, outcomes.

Key Points

  • Frequent haemodialysis, prolonged haemodialysis, and particularly the combination of both (frequent long haemodialysis), have been associated with improved uremic solute removal and better outcomes

  • Frequent haemodialysis, prolonged haemodialysis, and frequent long haemodialysis are more easily applied in a home dialysis setting than in-centre, owing to the increased time flexibility in the home setting

  • Even when using alternative time schedules, the minimal conditions of standard adequate dialysis should be pursued; that is, Kt/Vurea should be targeted according to the current guidelines and high-flux membranes should be used if possible

  • Regulatory bodies do not take into account the increased costs for consumables, electricity and water for these alternative home-based schedules

  • Owing to the time flexibility it enables, home haemodialysis also facilitates achievement of adequacy even in situations where blood flow is limited by compromised or smaller access systems

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Authors and Affiliations

  1. Department of Internal Medicine, Nephrology Section, University Hospital 0K12, De Pintelaan 185, Ghent, B9000, Belgium

    Raymond Vanholder, Sunny Eloot, Nathalie Neirynck & Wim Van Biesen

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  1. Raymond Vanholder
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  2. Sunny Eloot
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  3. Nathalie Neirynck
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  4. Wim Van Biesen
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Contributions

All authors contributed equally to researching data for the article and to discussions of the content. R. Vanholder wrote the article and reviewed/edited it before submission.

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Correspondence to Raymond Vanholder.

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Competing interests

The department of R. Vanholder has received unrestricted research grants from Gambro, Baxter Healthcare, Fresenius Medical Care and Bellco. R. Vanholder is on the advisory board of Baxter Healthcare (home haemodialysis program) and Johnson and Johnson. R. Vanholder and W. Van Biesen received speaker's honoraria from Fresenius Medical Care. N Neirynck receives travel support from Bellco. S. Eloot declares no competing interests.

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Vanholder, R., Eloot, S., Neirynck, N. et al. Home haemodialysis and uraemic toxin removal: does a happy marriage exist?. Nat Rev Nephrol 8, 579–588 (2012). https://doi.org/10.1038/nrneph.2012.189

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