HOME DIALYSIS

The Guide to Starting Home Dialysis

Contents

Introduction 4

  1  A good time to start with home dialysis 5

  2  How Fresenius Medical Care supports your home dialysis programme 7

  3  How to start a home dialysis programme 8

  4  Your extended offer – the home dialysis modalities 10

  5  Building the team 14

  6  Manpower requirement planning 17

 7  Infrastructure 19

  8  Eligibility and recruitment of patients 21

  9  Pre-dialysis education 24

10 Training 26

Infobase & References 28

THE GUIDE TO STARTING HOME DIALYSIS3

Introduction
This guide is designed for health care
professionals starting or expanding a home
dialysis programme on peritoneal dialysis and
home haemodialysis.
Fresenius Medical Care is ready to help you
bring dialysis HOME.
• Dialysis at home with either Peritoneal
­Dialysis (PD) or Home Haemodialysis (HHD)
represents a reliable and established form
of long-term therapy.
• It provides good care for all parties
­involved: p
­ atients, the therapeutic team
and the care giver.
• With this booklet, we are glad to offer our
support for starting your home dialysis
­programme.
• You will find a concise description of the
­necessary steps for implementing dialysis
at home for your patients: the organisa­
tional prerequisites, personal planning as
well as patient recruitment and training
requirements are all presented.
4
We remain at your disposal to support you!
Please do not hesitate to ask
your Fresenius Medical Care
­representative about our further
­support offering.
THE GUIDE TO STARTING HOME DIALYSIS
1  A good time to start with home dialysis
Home dialysis – the option of choice! In a preference is to “stay at home”.3
survey completed in 2012 the majority of
In the beginnings of chronic dialysis therapy 1
nephro­logists would choose home dialysis if
in the 1960s home dialysis was the only
they became dependent on renal replacement
­available survival option for most patients.
therapy themselves, while only 6% would
Nowadays the differences regarding the
decide on in-centre haemodialysis. They also 2
number of patients enrolled in home care
estimated that home dialysis could be an ideal
dialysis programmes throughout the world
option for about 30% of their dialysis
are strikingly different and range from 3% to
patients.1 3
over 50% (Fig. 1 + 2).
Another study investigating the effects of
It is a fact that the number of patients who
­predialysis education revealed that 30 – 50%
dialyse at home does not generally increase 4
of informed patients choose home modalities.2
as expected in the face of the current “peri­
From the patients’ perspective, home dialysis
toneal dialysis first” 4, 5 recommendations and
therapy allows individuality and flexibility,
that home dialysis is underused in many 5
which are prerequisites for rehabilitation and
­regions. It is also true that once the structures
employment and also yield an enormous
for home dialysis are established, the
­benefit in terms of quality of life and better
numbers of patients who are enrolled 6
outcomes. Dialysis at home enables new
increase. It is accepted that many factors
6
treatment options for frail patients or those
favour home dialysis therapies. The medical
with cardio-renal syndrome. We have found
that once the patients are “at home”, their
evidence is convincing, and argues for a 7
strengthening of its role.7, 8
8
THE GUIDE TO STARTING HOME DIALYSIS5
10
 2 How Fresenius Medical Care supports
your home dialysis programme


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 and qualified personnel. These can be ­recruitment / pre­
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overcome with home therapy: a favourable 2

patient-staff ratio and moderate investments
7. Continuing
Fig. 1: Adapted from USRDS; 2017 ADR Reference Fig. 2: Adapted from USRDS; 2017 ADR Reference in the necessary infrastructure speak for care
­Tables; Table N.7.b. https://www.usrds.org Tables; Table N.7.c. https://www.usrds.org
themselves. Herein lies the economic 3


potential of home therapies. Whether you are With our support and your ambition, a
The economic and health policy aspects Dialysis at home is a reliable and established considering a possible future with home successful home dialysis programme is within
speak in favour of home dialysis. It is also cost therapy. It promises benefits for all of those dialysis or if your decision is made, Fresenius reach for your institution and your patients. 4
effective: the investment for the home set-up involved: patients, the therapeutic team and Medical Care is ready to support you with the
and training is paid off with lower costs for the provider. When reading this booklet, you can follow
setup of your home dialysis programme,
staffing and facilities within a reasonable time your personal interests: every chapter is self-
whether Peritoneal Dialysis (PD) or Home 5
span.9, 10 Offering home dialysis therapies contained, allowing you to start reading what
Expanding the therapy range by Haemodialysis (HHD) is required.
is also an advantage in a competitive market you find the most interesting.
home dialysis offers a competitive
and a
­ llows a centre to grow. It also saves We can provide you with the information that
advantage and ­allows a centre to 6
staffing resources and ameliorates shortages you need to master the educational,
grow. Fresenius Medical Care is ready
of in-centre dialysis capacities. organisational, technical and financial aspects.
to provide you support with the
In ad­dition to this booklet, we offer
comprehensive materials and services: from
­successful setup of your home 7
­dialysis programme.
patient initiation, access and prescription to
home installations, home supply and 24/7
support.
8

6 THE GUIDE TO STARTING HOME DIALYSIS THE GUIDE TO STARTING HOME DIALYSIS7
10
3 How to start a home dialysis programme
If you meet patients who dialyse at home and
experience their contentment, you will already
know how rewarding the efforts to start up a
home therapy programme are. To enable you
to achieve a working daily routine, we are
glad to offer you the required information and
guidance for your project.
Bringing dialysis HOME: the elements of a
successful home dialysis programme are:
• good predialysis education, enabling
­patients to choose the therapy that suits
them most
• thorough and individualised patient training
• a qualified and dedicated home dialysis
team
It is important that you identify your potentials
and needs first based on where you are
­starting from. Next, you may want to discuss
how to overcome gaps and barriers and
where to find support. A project plan, good
communications within the team and
transparency are all highly recommended. It is
also essential for you to define responsibilities.
With this guide, the selected key literature and
our support, you are able to take the first
8
steps. The economic should not be neglected: a Demographic facts might also be taken into
home dialysis programme needs funding and account: in regions with a stable or declining
Empowering the team will be crucial for 1
a detailed modelling of costs. Generally, home prevalence of dialysis patients it can be prof­
overcoming any potential anxieties and
dialysis is considered less expensive than itable to reduce unused in-centre dialysis
reluctance. The thorough training of the team
in-centre treatment.9, 10
Reimbursement is an ­capacities. In contrast, in regions with a
members before enrolling the first patients will
important factor. Personnel and capital costs growing dialysis population, peritoneal 2
give them a lot more confidence. Further
are reduced when the infrastructure is par­ ­dialysis (PD) in particular can ensure the
support could be obtained from experienced
tially moved to the patients’ homes and when availability of the necessary treatment.
home dialysis clinics. If you are new to the
patients manage their own self-care. 3
field of home dialysis therapy, you will enjoy a
steep learning curve and gain a lot of new The key elements of a successful
experience on the job. home dia­lysis programme are
4
pre-dialysis education, patient training
Your programme can be started at your
and care which is provided by
­existing facility. To enable you to grow faster
a multidisciplinary ­dialysis team.
5
and beyond 5 –10 patients, you will need a
new infrastructure in regards to space and
staff. Otherwise, the number of home patients
will be limited to a few and the project will not 6
meet the support needed, since it will be
considered to be as an extra burden on an
already busy working day. We encourage you 7
to give your new project generous support
and to equip it with the necessary workforce
and tools from the very beginning as far as 8
possible.
9
THE GUIDE TO STARTING HOME DIALYSIS THE GUIDE TO STARTING HOME DIALYSIS9
10

4 Your extended offer – the home
as a filter to clean the blood and
removes excess body water.
In your extended programme, two modalities
are available that you can offer to the right
patients: peritoneal dialysis (PD) and home
haemodialysis (HHD). Transitions between
­different forms of kidney replacement therapy
that are adjusted to needs and opportunities
allow you to provide the optimum care to your
patients throughout their time on dialysis.
The conditions and decisions vary over time
– dialysis can offer a more variable journey
than the one-way track to in-centre
haemodialysis. This is not only true for those
patients who accomplish many years of life
with renal replacement therapy. Transitions
between therapies, e.g. starting with PD
then moving to haemodialysis, can
provide a longer ­dialysis time and may
better preserve residual renal function and
vascular access.
10
everybody’s abdomen. solution is drained and replaced with
fresh PD solution.
A thin lining called the peritoneal
membrane covers this space. This process is called an exchange
and is repeated 4 to 5 times a day.
The peritoneal membrane is used
dialysis modalities
In peritoneal dialysis, a PD solution
is used to fill the peritoneal cavity
through a small plastic tube called
a catheter. The PD solution remains
there for several hours, this is called
the dwellPeritoneal
time. Dialysis (PD)
6
PD is considered to be the modality of choice
KOPatBroch_12.10_GB.indd 6
for most patients starting on dialysis: it is
­relatively gentle, and residual renal function
is better preserved, which is an important
factor regarding quality of life and a long-term
medical success strategy. Moreover, PD
does not require water treatment or complex
technical installations and the training of the
patient can often be accomplished within just
one week.
THE GUIDE TO STARTING HOME DIALYSIS
PD has also contraindications. The main
complication of PD is peritonitis, which can
often be treated in an outpatient setting. The
peritoneal catheter insertion is a skill that can
be adopted fast and, if surgically performed,
can also be combined with the repair of
hernias.
Continuous Ambulatory Peritoneal Dialysis
(CAPD) with 2 – 4 exchanges of dialysate
­during the day is used most frequently.
Automated Peritoneal Dialysis (APD) which
is performed with a cycler can be a preferred
option for patients who go to work, because
20.12.10 14:42
it enables freedom from fluid exchanges during
daytime. For patients or children who need
practical support, assisted PD is an option: it
is performed with the help of trained care­
givers, visiting helpers or health care
professionals. In this situation, APD offers
the ­advantage of only requiring help twice a
day – at the start and the end of the
THE GUIDE TO STARTING HOME DIALYSIS11
treatment.
Intermittent peritoneal dialysis (IPD) uses 1
multiple short dwell exchanges, possibly
cycler-­assisted, 3 or 4 days a week. IPD is
generally performed in a dialysis centre and
2
can be a good option for elderly patients with
significant comorbidities.
The use of a cycler is also helpful if PD is used 3
for an urgent or unplanned dialysis or in the
case of acute kidney injury, as well as during
the initial weeks of PD-treatment if a faster 4
resolution of uremia, volume overload or supine
treatment is needed.
5
Typically patients present to the dialysis clinic
for a check-up visit, depending on their status
and stability, every four weeks. The visits as 6
well as the training can also be organised at
the patient’s home. According to several
factors, such as changing treatment
7
outcomes, patient’s conditions or social
­circumstances, some patients may require
10
 transition to transplantation or to haemodia­ time schedules of a dialysis centre, therefore home. Self-care in a satellite centre offers the os­mosis and the water treatment are more
lysis. making it easier to adapt the dialysis to the advantages of home dialysis with fewer costly; however, the equipment is not lost if a
person’s daily life, especially if the patient barriers to overcome, and can be a great patient should transfer from HHD. Also, the 1
Setting up a PD programme usually requires
­decides to dialyse during the night. Moreover, bridge to home. expertise for haemodialysis is already
solid initial input from the therapeutic team:
Details about haemodialysis extended home haemodialysis treatment, either available in the dialysis centre and the training
new skills need to be acquired and the lack of The commitment to HHD seem to be a lot
with longer durations or more frequent of the patients can be partially integrated into 2
experience canworks
How haemodialysis be a concern during the greater compared with PD, but it nonetheless
sessions, has proven to be favourable the routine dialysis sessions. Patients can

Your home haemodialysis treatment

­initial period. However,
The haemodialysis treatment is performed the rewards when the results in cost-effectiveness, given that the
several hours, several times a week. regarding the quality of life, and for selected frequently undergo HHD for many years, and
medical success is achieved are high, and waiting time to transplantation is not excessively
Haemodialysis removes extra fluid and
waste products from your body by moving
patients, may even be alternative outcome to only require limited support from the centre. 3
theyourpatient
blood through enjoys
a filter. The filter,a new sense of freedom. short.13,14 The training of the patient needs
known
as a dialyser or artificial kidney, is used with kidney transplantation. 11, 12
A shunt or a
a dialysis machine. During the treatment, time, the installation and continuous technical
Home Haemodialysis
a portion of blood is pumped through a permanent central vein catheter can be used.
specially prepared tubing set called the
support at patients’ homes are slightly more
bloodlines to the dialyser.
Self-cannulation can be mastered within Home dialysis is complementary 4
pump complex compared with PD. The initial
short time, and is not usually a major to in-centre treatment and trans­
investment in a dialysis machine, the reverse
obstacle. Visits to the dialysis clinic for check- plantation. The typical modalities are
venous
ups are usually scheduled about every 4 –12 CAPD, APD and HHD. Timely 5
weeks. Both the visits and some of the
blood

dialysate out
­transitions between therapies can
filter
arterial
blood
training can also be ­organised at the patient’s offer more optimum care during
dialysate in

the course of a patient’s dialysis 6

­journey.

7
HHD has many advantages over in-centre 18

treatment: it allows for freedom from the strict

HHD_TherapyInfo_12_17_MT-EN.indb 35 06.12.17 15:26

12 THE GUIDE TO STARTING HOME DIALYSIS THE GUIDE TO STARTING HOME DIALYSIS13
10
5 Building the team
The professional team guides the patient’s
journey from their predialysis education to
dialysis at home. The home dialysis team
con­tributes professional, organisational and
personal skills. Recruiting the team from your
own staff offers the advantage that they are
already familiar with the structures of your
­institution and also offers new career options.
Self-confidence is strengthened due to
­continuing education and training. As the
programme grows, new members will be
­integrated into the team and adjustments to
workflows and the organisation are required.
A team leader, who is responsible for the
­development of the programme is required
from the outset. This may be a dialysis nurse
but may also any other member of the team.
Extensive knowledge and experience with
PD and HD are of considerable value.
Furthermore, the conviction that dialysis at
home and self-care are beneficial and
worthwhile, as well as personal initiative and
leadership qualities, are also required.
External coaching can be considered for the
purpose of backing up the swift development
14
of a stable team.
The nephrologist decides and advises about
the therapy and changes of modality. Stable
patients are usually seen on an outpatient
basis about once a month. With the input of
the home dialysis nurse, the patient visits
should be well or­ganised and time efficient.
Patients who are new in the home-programme
can require more attention for adjustments
to their therapy. Multimorbidity is also a well-
known factor in in-centre dialysis: the higher
the commitment of the nephrologist, the better
the outcome for the patient – and the better
the success and growth of the programme.
Knowledge of home dialysis therapy is no
longer as widespread as it was during the early
years of dialysis. This means that, the
experience of physicians is variable ­according
to what is covered during nephrology the
training and additional training, shall be
provided to maintain this wealth of
THE GUIDE TO STARTING HOME DIALYSIS
experience in the hands of the nephrologists.
The home dialysis nurses are the key
persons: they have the most patient contacts
and are responsible for the quality and safety
of the therapy. Preconditions are a cooper­
ative and thorough working approach and the
willingness to respond to unforeseen
situations.
They oversee the outpatient clinic, the
predialysis education and the home dialysis
training. They accompany the catheter
insertion and hospital stays, and are ready for
emergencies. They provide support at home
as well as to the family, partners and other
caregivers. They offer guidance when a
transition to another therapy modality is
needed. Their responsibility includes ordering
products and their delivery, charting, quality
management and technical matters.
They need to have expertise, teaching ability,
the ability to motivate patients and a team
and a high level of responsibility. The level of
THE GUIDE TO STARTING HOME DIALYSIS15
job satisfaction for the right kind of enthusi­
astic person will be high.
1
Surgery is, in most cases, required for creating
the vascular access and the insertion of the
PD catheter. The referral for vascular surgery
2
will be similar as it is for in-centre patients. In
terms of the PD catheter insertion, cooperation
and training will be necessary in the case
3
of a lack of surgical experience. Laparoscopic
placement avoids omental adherence and
is preferable if available. In the initial phase of
4
the project, support from an experienced
centre can be very helpful (or even an
alternative) so as to avoid leaks, catheter cuff
5
extrusion and drain age problems if local
expertise is unavailable.
Hospital care will also be needed in the case 6
of complications, e.g. PD peritonitis or other
intermittent medical conditions. The
cooperation preferably with a local hospital to 7
8
10

coor­dinate the care and dialysis therapy for
the patients will depend on the local
circumstances.
Technical support for home haemodialysis
can be provided in a similar way as that at the
dialysis centre, either by the staff team or on
16
a service basis. The technical requirements for
PD are relatively small, and almost exclusively
related to the maintenance of the cyclers.
Depending on the local conditions, the team
could also include dieticians, social workers
and administrative staff, as well as nurses or
trained helpers for assisted dialysis.
The tasks of the dialysis nurses are
both comprehensive and rewarding.
They are the key persons for the
home dialysis team as they coordinate
the patient’s care, and are also the
binding link to the home dialysis team.
THE GUIDE TO STARTING HOME DIALYSIS
6 Manpower requirement planning
Building the team also means assessing your
staffing needs. In this chapter, we discuss
the essential aspects. With this information,
you can assess your requirements.
During the first year, the workload for the
home dialysis nurses can be high organising
the home dialysis programme, recruiting
­patients, providing the pre-dialysis education,
training the new patients and the continuous
care of p
­ atients that are already enrolled in the
­programme – all mean that the days will be
busy.
At the very start, you may have only a few
patients, so you still have enough time for
­organisational work and the planning. During
the initial phase of your programme the
number of patients gradually increases and
there is a lot of training to be completed.
­During this time, it is a good idea to plan a
full-time member of staff who oversees
10 –12 patients. You should also consider
holiday time, training time and eventual sick
leave – arranging for two part-time nurses
may be a good plan.
THE GUIDE TO STARTING HOME DIALYSIS17
When you get to 15 patients, be prepared to
enlarge your team. Once you have enrolled
a stable group of patients you will need less 1
time for training and more for your clinic and
the day-to-day support. As your experience
grows and a stable routine is established, a 2
ratio of one full time nurse for 20 – 25 patients
is a realistic assumption.15
3
It may be tempting to start your programme
“on top of the everyday business”. A better
choice could be to reorganize the in-center
4
dialysis situation and to give the home
programme a good start with a dedicated
team working independently.
5
Knowing the number of dialysis patients that
start new in your centre during a year allows
to estimate the number of patients you might 6
want to enroll in your home programme.
­Demographics, comorbidities, complications
and the waiting time to transplantation 7
determine how many patients leave the
programme. With these assumptions, you
have an ori­entation for quantitative and 8
qualitative staff ­demand planning.
10

Let us take a closer look at the workload that
you can expect:
The number of home dialysis patients that you
decide to enroll in a home programme
determines the workforce that you need. Set
yourself a goal, let’s say you want to get 20%
of your overall patients to dialyse at home –
either PD or HHD. This means that over time
up to 20% of your patients who are starting
new on dialysis will go for home therapy. To
start with, you might want to enroll suitable
patients that you already know from your in-
centre facility.
Now let us consider the training capacity you
will need:
PD training: The majority of your patients will
be PD patients. The International Society of
Peritoneal Dialysis (ISPD) has designed a 5-day
teaching programme with 3 hours of training
per day.16 Allowing extra time for individual
requirements, care and home visits, it is a
good idea to calculate two weeks and 30
hours per training.
18
HHD training: A goal of 5 % means a handful
of patients for small centres, but a considerable
number for a large institution.
The HHD-training consists of about 30 sessions
lasting 3 – 4 hours. With a typical schedule of
three training treatments per week, this might
take about 10 weeks. Alternatively, you and
the patient could decide on a more
comprehensive schedule with more training
sessions with shorter treatments, e.g. 5
weeks with 6 sessions each. Extra time is
needed to oversee the installation at home and
home visits, amounting to about 150 hours
to complete the training.17 The manual from
the International Society of Haemodialysis
(ISHD) provides a lot of valuable information
on how to make the appropriate
calculations.18
During the initial phase of your home
dialysis programme, a ratio of 1 full
time nurse for every 10 –12 patients
may be practical.
THE GUIDE TO STARTING HOME DIALYSIS
7 Infrastructure
As with your staff planning your requirements
regarding the infrastructure will be oriented to
the expected number of home dialysis patients
in your programme and the size of your
institution. Sometimes, a few organisational
changes and the reallocation of some existing
rooms will be sufficient. Construction work
may be required for larger projects. If space is
scarce, you should consider moving certain
functions, such as the PD-training, to
patients’ homes. Try to create a comfortable,
quiet atmosphere with enough room for
relatives and caregivers. The hygienic
requirements must also be taken into account.
Outpatient clinic
In your outpatient clinic, you will want a
reception and seating area, consulting rooms
and treatment rooms. A lecture room for the
predialysis training and group events is also
needed, which can be situated elsewhere. A
separate training room is a good idea if you
have the space.
THE GUIDE TO STARTING HOME DIALYSIS19
PD
The treatment room for PD has many
functions: physical examinations, diagnostic 1
tests such as the Peritoneal Equilibration Test
(PET), catheter exit care, training, emergency
care and other tasks. A stretcher or a reclining 2
chair are often used, a sink to drain the bags is
also necessary. A workstation for the
documen­tation and ordering products is also 3
needed. Since a large supply of PD solutions
is needed, ample storage space, although not
necessarily in the same room, is helpful. The 4
PD treatment room can also be used for
other tasks. It is recommended not to use it
for septic ­duties, however. In the case of an 5
unexpected visit of a PD patient or an
emergency, you will need rapid access to the
treatment room. The consultation with the 6
nephrologist can take place in the treatment
room or a separate consulting room or your
work may be more time-efficient if you switch 7
between two or more fully equipped
treatment rooms. This depends on how you
organise your clinic. 8
10

HHD
The tasks performed in the HHD treatment
room are less varied physical examinations,
shunt and catheter care, documentation and
ordering products. Special consideration
should be made to the training area. Ideally,
you will train one patient at a time in a separate
room which is quiet and allows for good
­levels of concentration. If a room within easy
reach of the dialysis center’s infrastructure
for water etc. is not available, the training room
can easily be equipped with a similar
installation as that in the patients’ house. This
is also advantageous if you plan to provide
the ­training out of the operating hours of the
dialysis centre.
20
HHD installation at home
The details regarding the equipment and the
installation in the patient’s home for haemodia­
lysis are provided in the ISHD manual.19 Your
Fresenius Medical Care representative will a
­ lso
be glad to support you with ideas and mate­
rials. As a rule, the same standards as those
for in-centre haemodialysis must be fulfilled.
A conventional single pass haemodialysis
machine with water pretreatment and a small
reverse osmosis offers the widest variety of
individual treatment options. Furthermore, if
you use the same machine at home as the
one in the clinic, all the nurses will be familiar
with the device and would be able to support
a 24/7 hotline for home haemodialysis patients
with any problems. Modern machines with
­integrated user guidance and online priming /
reinfusion allow for greater security and
­haemodiafiltration (HDF), save water, energy
and waste, allow for digital data transfers
and render the delivery of saline bags
unnecessary.
THE GUIDE TO STARTING HOME DIALYSIS
8 Eligibility and recruitment of patients
If you look at your patients, who would you
regard eligible for home therapy? Maybe not
so many. Do you think they are too elderly, too
sick, too difficult? Challenge your mind-set!
Looking at New Zealand, with almost 20%
of its patients on home haemodialysis and
Denmark, with over 20% of patients on PD,
shows that a successful home programme for
more patients is achievable. Dialysis at home
should be regarded as your first option. You
could assess your patients now and r­ eview
your assessment after you have gained more
information.
Beyond the medical arguments, the patient’s
ability for self-observation and their willingness
to adhere to their therapy are important
Patient on CAPD
THE GUIDE TO STARTING HOME DIALYSIS21
prerequisites. A trusting relationship between
you and your patient is indispensable. Patients
with a high need for autonomy can benefit 1
particularly strongly from selfcare. Enabling
patients to proceed to home dialysis also
means transferring responsibility and allowing 2
for a new scope of decision-making. That
implies that you will need adapt your role as
clinicians and specialists. 3
The preconditions for your patient’s decision­-
making process are information, the provision
4
of thorough training and support when at
home.19, 20 Sharing the experiences of patients
already dialysing at home is also helpful. It
5
may be easier for patients to decide on home
dialysis if they have not experienced in-centre
dialysis before. Counseling patients about their
6
dialysis early enough to enable them to cope
with their grief and to adjust to the new
perspective before dialysis therapy becomes
necessary is recommended. The same is also
7
true for a modality-switch or any transfer to
in-centre dialysis. Of course, different attitudes
and openness to discussions should also be
8
respected.
9
10
When starting the programme, you might
want support with assessing your patients.
“MATCH-D” may be used as a tool for gaining
a clearer picture of your patients and
objectifying your decisions and your patients’
de­cision-making processes and can also be
used on mobile devices. 21, 22
A home visit will
give you a lot of valuable information. Your
Fresenius Medical Care representative will
be also glad to support you with further ideas
and materials.
The possible candidates for home therapy
also include those patients with a failing
transplant or declining peritoneal function
who may need to transfer to home
haemodialysis. You might want to get in
Patient on APD
22
contact with transplant units. With frail
haemodialysis patients for whom transport to
and from a dialysis is ­already a constraint, PD
can be a great relief. When introducing PD,
you could also offer new possibilities for
patients with cardio-renal syndrome.
Communication with cardiologists and
general practitioners can help you to ­recruit
candidates from an enlarged circle of
patients.
Caring relatives and psychosocial factors
­deserve special attention: the inner conflicts
between the obligations and demands can
be overwhelming. Responsibilities need to be
defined, counselling, support and exit
strategies also needed to ease the strain. The
Patient on HHD
THE GUIDE TO STARTING HOME DIALYSIS
overall situation needs to be looked at. The major reason for deciding against the home
burn out of the dialysis partner is a major therapy.
reason for dropping out of the home dialysis 1
The physical and cognitive restrictions of the
therapy. Worries that the patients have about
patient and partner as well as the situation at
burdening their families and partners are a
home as regards space, cleanliness, water
2
and the e
­ lectricity supply will also need to be
considered.
3
Objective evaluation can reveal that
a significant number of your patients
are eligible for home therapy. 4
5
9
THE GUIDE TO STARTING HOME DIALYSIS23
10
9 Pre-dialysis education

Information is a prerequisite for enabling Patient Education Programme

­patients to decide between the options, to build
a new perspective and to adapt to a new life
situation. An early discussion is helpful and
supports coping with the future need for renal
replacement therapy. Perceived barriers
­towards home dialysis therapy on the part of
the patient shall be understood in order to
overcome them. Pre-dialysis education has an
impact on the patients’ decisions  , and
23
­patients who partake in the modality selection
are more satisfied with their treatment.24
A good time for the predialysis education is
1– 2 years before the expected start of the
­dialysis. This also provides time for
constructing the v­ ascular access and the
evaluation for transplantation if the idea of a
living kidney donation is considered.
Kidney Options
Guiding you when kidneys fail
Kidney Options – a patient education p­ rogramme
­available from Fresenius Medical Care
Predialysis education needs a structured
­programme and more time than a clinic
consultation allows. Kidney Options has been
­designed by Fresenius Medical Care to
support patients and their families, as well as
the entire nephrology team in assisting the
­patients to become better informed about
KOPatBroch_12.10_GB.indd 1
In addition to the objective information
presented by the dialysis team, the
opportunity to gather information from
patients who are ­already mastering home
dialysis is very valuable and helps to build
their self-confidence.
It is likely that word of mouth and social media
will spread the word about your new offer
of home dialysis therapy quickly to those who
are already interested or waiting an oppor­
tunity to try it out. Predialysis education will also
allow you to gain a wider audience among
your kidney patients and their relatives. If you
extend the predialysis education and infor­
mation events to settings outside your clinic,
you will further increase the catchment area.
20.12.10 14:42
Open house days or platforms like the World
Kidney Day are also suitable for spreading
­information. Professionals – physicians, nurses 1
and other caregivers can be addressed on a
more professional basis.
2
Predialysis education provides the
information that patients need
3
to ­decide about renal replacement
­therapy and self-management.
4
5
6

the treatment o
­ ptions for chronic renal failure.

24 THE GUIDE TO STARTING HOME DIALYSIS THE GUIDE TO STARTING HOME DIALYSIS25
10
10 Training
Under ideal circumstances, one nurse will
guide the patient through the whole process,
although often it is a team of two trainers for
organisational reasons. The degree of support
that the patient needs and the extent to which
a partner is trained is an individual decision.
Closer and individualised follow up sessions
after the transfer from the training to the home
is necessary for both, peritoneal dialysis and
home haemodialysis.
PD training
The details on when and where to start the
training may vary a lot: the training while in
hospital after the catheter placement, in the
clinic as an outpatient or at home depends on
the setting and the patients. The 2016 ISPD
guidelines on peritoneal dialysis training provide
a detailed base of information and set out a
five-day teaching programme.16, 25 The use of
IPD and assisted APD for the bridging allows
an early start to the dialysis in the case of
­severe uremia or fluid overload, and individually
adapted training sessions. If the patient
requires a lot of assistance, APD is a good
26
opportunity to relieve partners or caregivers
from the periodical bag exchanges. The
transfer from the training centre a patient’s
home will lead to temporary insecurity. In
most cases, the first training phase that
enables the patient to dialyse at home can be
completed within one to two weeks. Initially,
you will want to follow the patient more closely
until the clinical situation and the self-care
are stable. Retraining is recommended when
necessary, e.g. after a peritonitis, catheter
­infection, prolonged hospitalisation or other
interruptions.
HHD training
The training is usually initiated when the
vascular access is stable. The preparation
and dismantling of the dialysis machine as
well as getting on and off may already have
been taught before. These are standardised
procedures: this part of the training can be
inte­grated into the routine in-centre dialysis
sessions to reduce the workload of the home
­dialysis team. Everything else, especially the
needling, hygiene, safety measures and
THE GUIDE TO STARTING HOME DIALYSIS
emergency management should be instructed WE REMAIN AT YOUR DISPOSAL
by the home dialysis nurses. The training can We hope that this booklet is a valuable starting
be scheduled 3x per week for about 3 months point for you to either build a home therapy 1
during the normal treatment, or 4 – 6x per offering or to expand it.
week over a shorter period. Learning requires
constant revision. Once it is fore­seeable that The support and service of Fresenius Medical 2
the training will be successfully completed, it Care is at your disposal to help you and
is time to start the installations at home. It your patients to start on your home therapy
might be useful to consider a ­potential time gap – whether CAPD, APD or HHD is required. 3
between completing the training and the first
commissioning at home due to the delivery
Please do not hesitate to ask your
planning for the equipment. The patient can
Fresenius Medical Care representa- 4
bridge this time by performing treatment in
tive about our support services.
the dialysis clinic or in a self–care centre with
immediate support if necessary. This also 5
makes transfers from the training centre to the
home less stressful.
6
Ideally one nurse will guide the
­patient through the whole
process. Training for PD and HHD
7
have ­different requirements.
8
THE GUIDE TO STARTING HOME DIALYSIS27
10
Infobase & References

  1. M
 erighi JR, Schatell DR, Bragg-Gresham  
JL, Witten B, Mehrotra R. Insights into
nephrologist training, clinical practice, and
dialysis choice.
 
Hemodial Int 2012;16:242-251.
  2. Lacson Jr E, Wang W, DeVries C, Leste K,
Hakim RM, Lazarus M, Pulliam J. Effects
of a Nationwide Predialysis Educational
Program on Modality Choice, Vascular
 
Access, and Patient Outcomes.
Am J Kidney Dis. 2011;58(2):235-242.
  3. A
 gar JWM. Home hemodialysis in
­Australia and New Zealand: Practical
problems and solutions.
Hemodial Int 2008;12:S26-S32.
 
  4. Chaudhary K, Sangha H, Khanna R.
­Peritoneal Dialysis First: Rationale.
Clin J Am Soc Nephrol 2011;6:447–456.
  5. Ivarsen P, Povlsen JV. Can peritoneal
­dialysis be applied for unplanned initiation
of chronic dialysis?.
NDT 2014;29(12):2201-6.
6. Honkanen EO, Rauta VM. What happened
in Finland to increase home hemodialysis?
Hemodial Int 2008;12:S11-S15.
7. H
 eaf JG, Wehberg S. Relative Survival
of Peritoneal Dialysis and Haemodialysis
Patients: Effect of Cohort and Mode
of ­Dialysis Initiation.
PLoS ONE 2014; 9(3);e90119.
8. M
 arshall MR, Hawley CM, Kerr PG,
­Polkinghorne KR, Marshall RJ, Agar JWM,
McDonald SP. Home Hemodialysis
and Mortality Risk in Australian and
New Zealand Populations.
Am J Kidney Dis 2011;58(5):782-793.
9. “ Health technology assessment of the
different dialysis modalities in Norway.
Report from Kunnskapssenteret
­(Norwegian Knowledge Centre for
the Health Services) No 19–2013”
ISBN 978-82-8121-830-7.
10. Ishani A, Slinin Y, Greer N, Wilt TJ,
­MacDonald R, Messana J, Rutks I, Wilt
TJ. Comparative Effectiveness of
Home-based Kidney Dialysis versus ­In-
center or Other Outpatient Kidney D
­ ialysis
Locations - A Systematic Review. VA ESP
Project #09-009; 2015.
11. P
 auly RP. Survival comparison between
intensive hemodialysis and transplantation
in the context of the existing literature
­surrounding nocturnal and short-daily
­hemodialysis. Nephrol Dial Transplant
2013;28:44–47.
12. M
 asterson R. The advantages and
­disadvantages of home hemodialysis.
Hemodial Int. 2008;12:S16–S20.
13. Young BA, Chan C, Blagg C, Lockridge
R, Golper T, Finkelstein F, Shaffer R,
Mehrotra R. How to Overcome Barriers
and Establish a Successful Home HD
Program. Clin J Am Soc Nephrol
2012;7:2023-2032.
14. Komenda P, Gavaghan MB, Garfield SS,
Poret AW, Sood MM. An economic
assessment model for in-center,
conventional home, and more frequent
home hemodia­lysis. Kidney Int.
2012;81:307–313.
15. “Home Dialysis Toolkit. Developed by
the Forum of ESRD Networks’ Medical
Advisory Council (MAC)”
http://esrdnetworks.org/resources/toolkits/
mac-toolkits-1/home-dialysis-toolkit
16. F
 igueiredo AE, Bernardini J, Bowes E,
Hiramatsu M, Price V, Su C, Walker R,
Brunier G. ISPD
Guideline / Recommendations: A syllabus
for teaching peritoneal dialysis to patients
and caregivers. ­Perit Dial Int 2016;
36(6):592–605.
17. K
 omenda P, Copland M, Makwana J,
Djurdjev O, Sood MM, Levin A. The
cost of starting and maintaining a large
home hemodialysis program.
Kidney Int 2010;77:1039-1045.

18. “ Implementing Hemodialysis in the Home.

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 A Practical Manual” http://www.ishd.org/
library/pdfs/HomeHemo_AllModules2.pdf
19. T
 hodis ED, Oreopoulos DG. Home dialysis
first: a new paradigm for new ESRD
­patients. J Nephrol 2011; 24(04):398-404.
20. Tuso P. Choosing Wisely and Beyond:
Shared Decision Making and Chronic
Kidney Disease. Perm J 2013;17(4):75-78.
21. “Method to Assess Treatment Choices
for Home Dialysis (MATCH-D)”
http://homedialysis.org/match-d
22. “ Calculate” https://qxmd.com/calculate-­
by-qxmd
23. Manns BJ , Taub K, Vanderstraeten C,
Jones H, Mills C, Visser M, McLaughlin K.
The impact of education on chronic
­kidney disease patients’ plans to initiate
30
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Kidney Int. 2005;68(4):1777-1783.
24. Van Biesen W, van der Veer SN, Murphey
M, Loblova O, Davies S. Patients’
­Perceptions of Information and Education
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­Therapy. PLoS ONE 2014;9(7):e103914.
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­Dialysis Training”. International Society
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nurses
THE GUIDE TO STARTING HOME DIALYSIS
Disclaimer:
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