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Chapter 8: Complications of Home Hemodialysis

Tushar Chopra; Lakshmi Kannan; Emaad M. Abdel-Rahman

INTRODUCTION

The crude prevalence of end-stage kidney disease (ESKD) is 2160.7 per million in the United States, with only 2% of these patients utilizing home hemodialysis (HHD).1 The number of HHD patients has increased in recent years and is expected to increase further following the introduction of the United States Department of Health and Human Services Advancing American Kidney Health Initiative. While HHD has been associated with multiple benefits,2–7 it is not without complications. Nephrologists must be knowledgeable about these complications as HHD use increases in the United States. In this chapter, we discuss technical, medical, and psychosocial complications associated with HHD and their diagnosis, management, and prevention.

GENERAL CONSIDERATIONS

The HHD room setup is quite important. In order to minimize the risk of complications, all screens for devices should be in direct line of sight with adequate lighting. The space utilized for HHD should have low humidity, a comfortable temperature, telephone access, and restricted access to children and pets. Availability of easy-to-use sinks with hands-free elbow taps would be ideal. All surfaces and furnishings should be easy to clean.

TECHNICAL COMPLICATIONS

The summary of technical complications is provided in Table 8-1.

Table 8-1Technical Complications
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Table 8-1 Technical Complications

Problem

Solution

Hemorrhage

At the access

Stop blood pump and apply direct pressure on access

Preventive measures

  • Secure needles at the insertion site

  • Keep dialysis access and tubing visible throughout the treatment

  • Use blood leak detectors

  • Disconnect the arterial needle before the venous needle

From the dialysis circuit

Keep dialysis access and tubing visible throughout treatment

Stop blood pump

Into the dialysis circuit

Heed blood leak alarm

Stop blood pump

Air embolism

Between access and blood pump

Heed air detection alarms

Clamp venous line

Stop the blood pump

Place patient supine

Call local emergency medical personnel

During connection

Heed air detection alarms

Clamp venous line

Stop the blood pump

Place patient supine

Call local emergency medical personnel

Air in dialysate

Venous chamber will trap small amounts of air

Heed air detection alarms

Clamp venous line

Stop the blood pump

Notify HHD unit

Water system problems

Chloramine breakthroughs

Notify HHD unit

Check activated carbon filters

Check to see if municipal water treatment has changed

Low-pressure RO feed alarm

Install booster pump to the water line

Stop other water-consuming equipment

Use “flow-fed” RO

Abnormal water temperature

Install necessary cooling

Use cooled heat exchanger

Maintaining water quality standards

Chloramine/Chlorine testing every treatment

Product water and dialysate testing per unit policy

Tap water AAMI water analysis prior to installation

AAMI, Association for the Advancement of Medical Instrumentation; HHD, home hemodialysis; RO, reverse osmosis.

Hemorrhage

Bleeding is an uncommon but serious complication of HHD. In two studies evaluating adverse events in HHD programs in Canada, blood loss was ...

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