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Technical aspects of nocturnal hemodialysis

Andreas Pierratos, MD, FRCPC
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD


The mortality rate of patients undergoing maintenance hemodialysis is unacceptably high [1]. An extremely high morbidity, relatively low quality of life (due in part to a high level of dependence and unemployment), and high cost of care have also been observed.

Instituting more intensive dialysis regimens appears to improve morbidity and possible mortality in this patient population. Compared with conventional three times per week regimens, for example, dialysis associated with longer duration and/or higher frequency correlates with enhanced outcomes [2-7]. However, the Hemodialysis (HEMO) study found that increasing the dialysis dose within the general restrictions of a thrice-weekly regimen failed to decrease patient mortality [8-10]. (See "Patient survival and maintenance dialysis" and "Prescribing and assessing adequate hemodialysis".)

Given these findings, nocturnal hemodialysis (eg, long nightly home hemodialysis) was introduced as a (possibly) more desirable alternative to conventional dialysis since it provides superior dialysis, based upon dose, duration, and frequency. This can be accomplished because it is performed during nightly sleep, an otherwise unproductive time [11].

Although Shaldon is credited for overnight dialysis at home [12], Uldall started the first quotidian (daily) nocturnal hemodialysis program in 1994 in Toronto [11,13]. Since then, its use has been extended to more centers in Canada, the United States, Australia, and several European countries [14-17].

A description of nocturnal hemodialysis, particularly the exact regimen associated with the procedure, will be presented here. Outcomes associated with nocturnal hemodialysis and an overview of short daily hemodialysis are presented separately. (See "Outcomes associated with nocturnal hemodialysis" and "Short daily hemodialysis".)


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Literature review current through: Sep 2016. | This topic last updated: Dec 16, 2015.
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  1. Morbidity and mortality. In: United States Renal Data System, Vol 2: 2010 Annual Data Report in the United States, http://www.usrds.org/2010/slides/indiv/1v2index.html http://www.usrds.org/adr.htm (Accessed on July 05, 2011).
  2. Saran R, Bragg-Gresham JL, Levin NW, et al. Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS. Kidney Int 2006; 69:1222.
  3. Charra B, Calemard E, Ruffet M, et al. Survival as an index of adequacy of dialysis. Kidney Int 1992; 41:1286.
  4. Buoncristiani U. Fifteen years of clinical experience with daily haemodialysis. Nephrol Dial Transplant 1998; 13 Suppl 6:148.
  5. Woods JD, Port FK, Orzol S, et al. Clinical and biochemical correlates of starting "daily" hemodialysis. Kidney Int 1999; 55:2467.
  6. Locatelli F, Buoncristiani U, Canaud B, et al. Dialysis dose and frequency. Nephrol Dial Transplant 2005; 20:285.
  7. Kjellstrand C, Buoncristiani U, Ting G, et al. Survival with short-daily hemodialysis: association of time, site, and dose of dialysis. Hemodial Int 2010; 14:464.
  8. Lowrie EG, Laird NM, Parker TF, Sargent JA. Effect of the hemodialysis prescription of patient morbidity: report from the National Cooperative Dialysis Study. N Engl J Med 1981; 305:1176.
  9. Hakim RM, Breyer J, Ismail N, Schulman G. Effects of dose of dialysis on morbidity and mortality. Am J Kidney Dis 1994; 23:661.
  10. Eknoyan G, Beck GJ, Cheung AK, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002; 347:2010.
  11. Pierratos A, Ouwendyk M, Francoeur R, et al. Nocturnal hemodialysis: three-year experience. J Am Soc Nephrol 1998; 9:859.
  12. Shaldon S. Independence in maintenance haemodialysis. Lancet 1968; 1:520.
  13. Udall PR, Francoeur R, Ouwendyk M. Simplified nocturnal home hemodialysis (SNHHD). A new approach to renal replacement therapy. J Am Soc Nephrol 1994; 5:428.
  14. Lindsay RM, Daily/Nocturnal Dialysis Study Group. The London, Ontario, Daily/Nocturnal Hemodialysis Study. Semin Dial 2004; 17:85.
  15. Lockridge RS Jr, Spencer M, Craft V, et al. Nocturnal home hemodialysis in North America. Adv Ren Replace Ther 2001; 8:250.
  16. Agar JW, Somerville CA, Dwyer KM, et al. Nocturnal hemodialysis in australia. Hemodial Int 2003; 7:278.
  17. Kooistra MP. Frequent prolonged home haemodialysis: three old concepts, one modern solution. Nephrol Dial Transplant 2003; 18:16.
  18. Lacson E Jr, Wang W, Lester K, et al. Outcomes associated with in-center nocturnal hemodialysis from a large multicenter program. Clin J Am Soc Nephrol 2010; 5:220.
  19. Al-Hejaili F, Kortas C, Leitch R, et al. Nocturnal but not short hours quotidian hemodialysis requires an elevated dialysate calcium concentration. J Am Soc Nephrol 2003; 14:2322.
  20. Barua M, Hladunewich M, Keunen J, et al. Successful pregnancies on nocturnal home hemodialysis. Clin J Am Soc Nephrol 2008; 3:392.
  21. Su WS, Lekas P, Carlisle EJ, et al. Management of hypophosphatemia in nocturnal hemodialysis with phosphate-containing enema: a technical study. Hemodial Int 2011; 15:219.
  22. Ing TS, Yu AW, Agrawal B, et al. Increasing plasma phosphorus values by enriching with phosphorus the "acid concentrate" of a bicarbonate-buffered dialysate delivery system. Int J Artif Organs 1992; 15:701.
  23. Geary DF, Piva E, Tyrrell J, et al. Home nocturnal hemodialysis in children. J Pediatr 2005; 147:383.
  24. Pierratos A. Daily nocturnal home hemodialysis. Kidney Int 2004; 65:1975.
  25. Kjellstrand CM, Blagg CR, Bower J, Twardowski ZJ. The Aksys personal hemodialysis system. Semin Dial 2004; 17:151.
  26. Ledebo I, Fredin R. The Gambro system for home daily dialysis. Semin Dial 2004; 17:162.
  27. Kelly TD. Baxter Aurora dialysis system. Semin Dial 2004; 17:154.
  28. Schlaeper C, Diaz-Buxo JA. The Fresenius Medical Care home hemodialysis system. Semin Dial 2004; 17:159.
  29. Clark WR, Turk JE Jr. The NxStage System One. Semin Dial 2004; 17:167.
  30. Ash SR. The Allient dialysis system. Semin Dial 2004; 17:164.
  31. Trewin E. Bellco Formula Domus Home Care System. Semin Dial 2004; 17:156.
  32. Pierratos A, Francoeur R, Ouwendyk M. Delayed dialyzer reprocessing for home hemodialysis. Home Hemodial Int 2000; 4:51.
  33. Twardowski ZJ. Dialyzer reuse-Part I: Historical perspective. Semin Dial 2006; 19:41.
  34. Faratro R, D'Gama C, Chan C. The use of alternative anti-coagulation strategies for a nocturnal home hemodialysis patient with heparin-induced thrombocytopenia. CANNT J 2008; 18:32.
  35. Bell RZ, Pichette V, Lafrance JP, et al. Efficacy and safety of tinzaparin anticoagulation of the extracorporeal circuit with a single bolus administration in nocturnal home hemodialysis. J Am Soc Nephrol 2014; 25:849A.
  36. Suri RS, Larive B, Sherer S, et al. Risk of vascular access complications with frequent hemodialysis. J Am Soc Nephrol 2013; 24:498.
  37. Pipkin M, Craft V, Spencer M, Lockridge RS Jr. Six years of experience with nightly home hemodialysis access. Hemodial Int 2004; 8:349.
  38. Eloot S, De Vos JY, Hombrouckx R, Verdonck P. How much is catheter flow influenced by the use of closed luer lock access devices? Nephrol Dial Transplant 2007; 22:3061.
  39. Hemmelgarn BR, Moist LM, Lok CE, et al. Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator. N Engl J Med 2011; 364:303.
  40. Twardowski ZJ. Stepwise Anticoagulation with Warfarin for Prevention of Intravenous Catheter Thrombosis. Hemodialysis Int 2000; 4:37.
  41. Wilkieson TJ, Ingram AJ, Crowther MA, et al. Low-intensity adjusted-dose warfarin for the prevention of hemodialysis catheter failure: a randomized, controlled trial. Clin J Am Soc Nephrol 2011; 6:1018.
  42. Perl J, Lok CE, Chan CT. Central venous catheter outcomes in nocturnal hemodialysis. Kidney Int 2006; 70:1348.
  43. Hayes WN, Tennankore K, Battistella M, Chan CT. Vascular access-related infection in nocturnal home hemodialysis. Hemodial Int 2014; 18:481.
  44. Twardowski ZJ, Harper G. Buttonhole method of needle insertion into arteriovenous fistulas. 1997.
  45. Twardowski Z, Kubara H. Different sites versus constant sites of needle insertion into arteriovenous fistulas for treatment by repeated dialysis. Dial Transpl 1979; 8:978.
  46. Hashmi A, Cheema MQ, Moss AH. Hemodialysis patients' experience with and attitudes toward the buttonhole technique for arteriovenous fistula cannulation. Clin Nephrol 2010; 74:346.
  47. Nesrallah GE, Cuerden M, Wong JH, Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis. Clin J Am Soc Nephrol 2010; 5:1047.
  48. MacRae JM, Ahmed SB, Atkar R, Hemmelgarn BR. A randomized trial comparing buttonhole with rope ladder needling in conventional hemodialysis patients. Clin J Am Soc Nephrol 2012; 7:1632.
  49. Zimmerman D, Lok CE. Accessing the access. Clin J Am Soc Nephrol 2012; 7:1548.
  50. Muir CA, Kotwal SS, Hawley CM, et al. Buttonhole cannulation and clinical outcomes in a home hemodialysis cohort and systematic review. Clin J Am Soc Nephrol 2014; 9:110.
  51. Moist LM, Nesrallah GE. Should buttonhole cannulation be discontinued? Clin J Am Soc Nephrol 2014; 9:3.
  52. Grudzinski A, Mendelssohn D, Pierratos A, Nesrallah G. A systematic review of buttonhole cannulation practices and outcomes. Semin Dial 2013; 26:465.
  53. Mustafa RA, Zimmerman D, Rioux JP, et al. Vascular access for intensive maintenance hemodialysis: a systematic review for a Canadian Society of Nephrology clinical practice guideline. Am J Kidney Dis 2013; 62:112.
  54. Vaux E, King J, Lloyd S, et al. Effect of buttonhole cannulation with a polycarbonate PEG on in-center hemodialysis fistula outcomes: a randomized controlled trial. Am J Kidney Dis 2013; 62:81.
  55. Wong B, Zimmerman D, Reintjes F, et al. Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective. Am J Kidney Dis 2014; 63:251.
  56. Pierratos A. Nocturnal home haemodialysis: an update on a 5-year experience. Nephrol Dial Transplant 1999; 14:2835.
  57. Hoy CD. Remote Monitoring of Daily Nocturnal Hemodialysis. Hemodialysis Int 2001; 4:8.
  58. Heidenheim AP, Leitch R, Kortas C, et al. Patient monitoring in the London Daily/Nocturnal Hemodialysis Study. Am J Kidney Dis 2003; 42:61.
  59. MATCH-D group. Method to assess treatment choices for home dialysis (MATCH-D). 2011. http://www.homedialysis.org/files/pros/MatchD2009.pdf.
  60. Pauly RP, Gill JS, Rose CL, et al. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant 2009; 24:2915.
  61. Leitch R, Ouwendyk M, Ferguson E, et al. Nursing issues related to patient selection, vascular access, and education in quotidian hemodialysis. Am J Kidney Dis 2003; 42:56.
  62. Cafazzo JA, Leonard K, Easty AC, et al. Patient-perceived barriers to the adoption of nocturnal home hemodialysis. Clin J Am Soc Nephrol 2009; 4:784.