Support

Country Websites
Offering Complete and Comprehensive Kidney Care

Home Hemodialysis Dosing

A Simplified Approach to Individualized Care

How to Prescribe Patient-Centered Home Hemodialysis
(HHD) in 3 Steps:

Clinical considerations for increased frequency

3 DAYS PER WEEK

 
  • Longer duration treatments (example: nocturnal) has improved mortality in observational studies1

EVERY OTHER DAY

  • May be able to avoid some risks associated with a 2-day gap in treatment2
  • May enable decreased ultrafiltration rate (UFR) by:3
    • Increasing time per treatment
    • Increasing number of treatments per week

5+ DAYS PER WEEK

More Frequent During Waking Hours
  • Improved survival4-6
  • Improved blood pressure (BP) control7-9
  • Reduced left ventricular hypertrophy7,10
  • Fewer cardiovascular hospitalizations10,11
  • Reduced ultrafiltration rate (UFR),12-14 recovery time,15,16 and hypotensive episodes14,17
  • Improved sleep quality,18,19 restless leg syndrome,18,19 & health-related quality of life19,20

More Frequent Nocturnal or Extended-Hours Hemodialysis

  • Additional benefits associated with ≥25 treatment hours per week:
    • Reduction in obstructive sleep apnea episodes21
    • Improved dialytic phosphorus control22-24
    • Reduction in post-dialysis recovery time15

Total weekly treatment time is driven by weekly patient fluid gains
and ultrafiltration rate (UFR)

Clinical Considerations for Decreasing Target UFR

Ultrafiltration rates at or below 8 mL/h/kg suggest lower mortality risk.25,26

Patients who receive conventional, thrice-weekly in-center HD have an average UFR of 9.4 mL/h/kg, and 41% of those patients have a UFR at or above 10 mL/h/kg.25

Patients who perform HHD more frequently have an average UFR of 6.0 mL/h/kg, and 14% of those patients have a UFR at or above 10 mL/h/kg.12

 

Read Additional Clinical Evidence Related To UFR

Calculating Treatment Time for Optimal Fluid Removal

To calculate the total treatment hours per week, start with the patient's weekly fluid gain in a given week, divided by the patient's weight.

Divide the weekly fluid needing to be removed by the ultrafiltration rate to calculate the total treatment time per week.

Total treatment time per week divided by the number of treatments per week is the number of hours per treatment.

Example: If a 80kg patient is putting on 9,600 mL of fluid per week, that must be removed. With a desired UF rate of 8 mL/h/kg, the result is a treatment time of 15 hours per week.

Factors affecting dialysate treatment volume

The per-treatment dialysate volume is determined by target Kt/V, total body water, frequency, duration and residual kidney function. Kt/V, or urea clearance normalized to patient total body water, is the standard by which hemodialysis adequacy is measured and compared. A weekly standard Kt/V (stdKt/V) target dose can be translated into a per-treatment single pool Kt/V (spKt/V) for any given treatment regimen (frequency and duration). The spKt/V and the patient’s total body water determine the volume per treatment at which the dialysate is efficiently used.

The figures to the left show the spKt/V that need to be achieved in a single treatment to achieve a stdKt/V of 2.1 and 2.3.27

Recommended treatment volumes by gender, weight and frequency

Low volume dialysate treatments have improved small solute clearance and saturation when the dialysate flow rate is approximately 1/3 (or less) that of the blood flow rate. The following table is an example of estimated volume of dialysate needed to achieve a standard weekly Kt/V of 2.1 for men, assuming shorter treatments and a dialysate flow to blood flow ratio of 30% to 40%.

For additional guides, for both women and nocturnal treatments, download the Dialysate Volume Quick Reference Guide.
 

Download Dialysate Volume Quick Reference Guide

NxStage® Dosing Calculator

Provides potential patient-specific therapy schedule options based on scientific peer-reviewed formulas and journals.

Used for:

  • Evaluating and discussing potential therapy options with new HHD patients
  • Evaluating flexible therapy options as current HHD patients' needs change

Resources

NxStage is devoted to supporting healthcare professionals

Dialysate Volume Quick Reference Guide

2-page PDF summary of HHD dosing best practices

 

Download PDF

Dosing Calculator Training Video

10-minute US Dosing Calculator training video, including settings and dosing considerations

 

Watch Video

Therapy Handbook

NxStage Hemodialysis Treatment Therapy Handbook

 

Download PDF

APM3536 Rev. D

Risks and Responsibilities

Patients should review the following information carefully and discuss it with their doctors to decide whether home hemodialysis with NxStage systems is right for them.

Users should weigh the risks and benefits of performing home hemodialysis with NxStage systems. 

  • Medical staff will not be present to respond to health emergencies that might happen during home treatments, including, among other things, dizziness, nausea, low blood pressure, and fluid or blood leaks.  
  • Users may not experience the reported benefits of home, more frequent, or nocturnal hemodialysis with the NxStage systems.
  • The NxStage systems require a prescription for use.    

Users will need additional resources to perform home hemodialysis.

  • Users will need a trained care partner to be present during your treatment at home (unless their doctor prescribes “solo/independent” home hemodialysis, described below).
  • Users must have a clean and safe environment for their home treatments.
  • Users will need space in their home for boxes of supplies necessary to perform home hemodialysis with NxStage systems.

Certain forms of home hemodialysis have additional risks. 

  • If a doctor prescribes home hemodialysis more than 3 times a week, vascular access is exposed to more frequent use which may lead to access related complications, including infection of the site.  Doctors should evaluate the medical necessity of more frequent treatments and discuss the risks and benefits of more frequent therapy with users.
  • If a doctor prescribes “solo/independent” home hemodialysis without a care partner during waking hours, risks of significant injury or death increase because no one is present to help users respond to health emergencies.  If users experience needles coming out, blood loss, or very low blood pressure during solo/independent home hemodialysis, they may lose consciousness or become physically unable to correct the health emergency. Users will need additional ancillary devices and training to perform solo/independent home hemodialysis.
  • If a doctor prescribes “nocturnal” home hemodialysis at night while the user and a care partner are sleeping, risks increase due to the length of treatment time and because therapy is performed while the user and a care partner are sleeping. These risks include, among other things, blood access disconnects and blood loss during sleep, blood clotting due to slower blood flow or increased treatment time or both, and delayed response to alarms when waking from sleep. A doctor may need to adjust users’ medications for nocturnal home hemodialysis, including, among other things, iron, Erythropoiesis-Stimulating Agents (ESA), insulin/oral hypoglycemics, anticoagulants, and phosphate binders.


References

  1. Rivara MB, Adams S V., Kuttykrishnan S, Kalantar-Zadeh K, Arah OA, Cheung AK, et al. Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal disease. Kidney Int [Internet]. 2016;90(6):1312–20. Available from: http://dx.doi.org/10.1016/j.kint.2016.06.028
  2. Foley RN, Gilbertson DT, Murray T, Collins AJ. Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis. N Engl J Med [Internet]. 2011 Sep 22;365(12):1099–107. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1103313
  3. Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, et al. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol [Internet]. 2019 Dec 17;20(1):379. Available from: https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-019-1527-3
  4. U.S. Renal Data System, USRDS Annual Data Report, vol 2, Table 6.3. 2015. 
  5. U.S. Renal Data System, USRDS Annual Data Report, vol 2, Table 6.3.; 2015 & Matched NxStage patient data on file. 
  6. Yeung EK, Polkinghorne KR, Kerr PG. Home and facility haemodialysis patients: A comparison of outcomes in a matched cohort. Nephrol Dial Transplant. 2021;36(6):1070–7. 
  7. FHN Trial Group. In-Center Hemodialysis Six Times per Week versus Three Times per Week. N Engl J Med [Internet]. 2011 Jan 6;364(1):93–93. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMx100103
  8. Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA, Komenda P. Intensive Hemodialysis and Treatment Complications and Tolerability. Am J Kidney Dis [Internet]. 2016;68(5):S43–50. Available from: http://dx.doi.org/10.1053/j.ajkd.2016.05.021
  9. Bakris GL, Burkart JM, Weinhandl ED, McCullough PA, Kraus MA. Intensive Hemodialysis, Blood Pressure, and Antihypertensive Medication Use. Am J Kidney Dis [Internet]. 2016;68(5):S15–23. Available from: http://dx.doi.org/10.1053/j.ajkd.2016.05.026
  10. McCullough PA, Chan CT, Weinhandl ED, Burkart JM, Bakris GL. Intensive Hemodialysis, Left Ventricular Hypertrophy, and Cardiovascular Disease. Am J Kidney Dis [Internet]. 2016;68(5):S5–14. Available from: http://dx.doi.org/10.1053/j.ajkd.2016.05.025
  11. Weinhandl ED, Nieman KM, Gilbertson DT, Collins AJ. Hospitalization in Daily Home Hemodialysis and Matched Thrice-Weekly In-Center Hemodialysis Patients. Am J Kidney Dis [Internet]. 2015 Jan;65(1):98–108. Available from: http://dx.doi.org/10.1053/j.ajkd.2014.06.015
  12. Cherukuri S, Bajo M, Colussi G, Corciulo R, Fessi H, Ficheux M, et al. Home hemodialysis treatment and outcomes: Retrospective analysis of the Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) cohort 11 Medical and Health Sciences 1103 Clinical Sciences. BMC Nephrol. 2018;19(1):1–10. 
  13. Deger SM, Korucu B, Ikizler TA. 34 - Nutritional Management of Hemodialysis Patients. In: Nissenson AR, Fine RN, Mehrotra R, Zaritsky J, editors. Handbook of Dialysis Therapy (Sixth Edition) [Internet]. Sixth Edit. New Delhi: Elsevier; 2023. p. 308–14. Available from: https://www.sciencedirect.com/science/article/pii/B9780323791359000343
  14. Kotanko P, Garg AX, Depner T, Pierratos A, Chan CT, Levin NW, et al. Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386–401. 
  15. Heidenheim AP, Muirhead N, Moist L, Lindsay RM. Patient quality of life on quotidian hemodialysis. Am J Kidney Dis. 2003;42(1 SUPPL. 1):36–41. 
  16. Jaber BL, Lee Y, Collins AJ, Hull AR, Kraus MA, McCarthy J, et al. Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: Interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. Am J Kidney Dis [Internet]. 2010;56(3):531–9. Available from: http://dx.doi.org/10.1053/j.ajkd.2010.04.019
  17. Murashima M, Kumar D, Doyle AM, Glickman JD. Comparison of intradialytic blood pressure variability between conventional thrice-weekly hemodialysis and short daily hemodialysis. Hemodial Int. 2010;14(3):270–7. 
  18. Jaber BL, Schiller B, Burkart JM, Daoui R, Kraus MA, Lee Y, et al. Impact of Short Daily Hemodialysis on Restless Legs Symptoms and Sleep Disturbances. Clin J Am Soc Nephrol [Internet]. 2011 May;6(5):1049–56. Available from: https://cjasn.asnjournals.org/lookup/doi/10.2215/CJN.10451110
  19. Kraus MA, Fluck RJ, Weinhandl ED, Kansal S, Copland M, Komenda P, et al. Intensive Hemodialysis and Health-Related Quality of Life. Am J Kidney Dis [Internet]. 2016 Nov;68(5):S33–42. Available from: http://dx.doi.org/10.1053/j.ajkd.2016.05.023
  20. Finkelstein FO, Schiller B, Daoui R, Gehr TW, Kraus MA, Lea J, et al. At-home short daily hemodialysis improves the long-term health-related quality of life. Kidney Int [Internet]. 2012;82(5):561–9. Available from: http://dx.doi.org/10.1038/ki.2012.168
  21. Hanly PJ, Pierratos A. Improvement of Sleep Apnea in Patients with Chronic Renal Failure Who Undergo Nocturnal Hemodialysis. N Engl J Med [Internet]. 2001 Jan 11;344(2):102–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11150360
  22. Daugirdas JT, Chertow GM, Larive B, Pierratos A, Greene T, Ayus JC, et al. Effects of frequent hemodialysis on measures of CKD mineral and bone disorder. J Am Soc Nephrol. 2012;23(4):727–38. 
  23. Copland M, Komenda P, Weinhandl ED, McCullough PA, Morfin JA. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. Am J Kidney Dis [Internet]. 2016;68(5):S24–32. Available from: http://dx.doi.org/10.1053/j.ajkd.2016.05.024
  24. Rocco M V., Lockridge RS, Beck GJ, Eggers PW, Gassman JJ, Greene T, et al. The effects of frequent nocturnal home hemodialysis: The Frequent Hemodialysis Network Nocturnal Trial. Kidney Int [Internet]. 2011;80(10):1080–91. Available from: http://dx.doi.org/10.1038/ki.2011.213
  25. Assimon MM, Wenger JB, Wang L, Flythe JE. Ultrafiltration Rate and Mortality in Maintenance Hemodialysis Patients. Am J Kidney Dis [Internet]. 2016;68(6):911–22. Available from: http://dx.doi.org/10.1053/j.ajkd.2016.06.020
  26. Mermelstein A, Raimann JG, Wang Y, Kotanko P, Daugirdas JT. Ultrafiltration Rate Levels in Hemodialysis Patients Associated with Weight-Specific Mortality Risks. Clin J Am Soc Nephrol [Internet]. 2023 Mar 10;Publish Ah. Available from: https://journals.lww.com/10.2215/CJN.0000000000000144
  27. Gotch FA. Modeling the Dose of Home Dialysis. Home Hemodial Int. 1999;3(1):37–40. 
  28. Leypoldt JK, Jaber BL, Zimmerman DL. DAILY HEMODIALYSIS—SELECTED TOPICS: Predicting Treatment Dose for Novel Therapies Using Urea Standard Kt / V. Semin Dial [Internet]. 2004 Mar 29;17(2):142–5. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.0894-0959.2004.17212.x
  29. Nesrallah GE, Suri RS, Lindsay RM, Pierratos A. Home and Intensive Hemodialysis. In: Daugirdas JT, Blake PG, Ing TS, editors. Handbook of Dialysis Therapy [Internet]. 5th editio. Philadelphia, PA: Elsevier; 2017. p. 305–20. Available from: https://hsrc.himmelfarb.gwu.edu/books/23
  30. Lockridge R, Cornelis T, Van Eps C. Prescriptions for home hemodialysis. Hemodial Int. 2015;19(S1):S112–27. 

APM2226 Rev. C

Calculations and Assumptions
Ktest = dialysate volume (Vd) x 0.9 (When Qd/Qb 30 – 40%)
Ktest = dialysate volume (Vd) x 0.95 (When Qd/Qb is <25%)

Estimated Total Body Water
VBW = 0.9 Watson28 – or –
VBW = 0.42 x wt (women)29
VBW = 0.50 x wt (men)29

Dialysate Volume
(0.9 x Vd) / 0.42 wt = spKt/V (women)
(0.9 x Vd) / 0.50 wt = spKt/V (men)

Calculate
Solve for Vd with known spKt/V based on frequency
Vd = dialysate + UF volume

Contact

Country Websites

All Contact Information

Social Media

© 2006-2024 Fresenius Medical Care. All Rights Reserved.

Privacy Statement

Terms of Use