Route to NHHD

Hello Dr Agar,

I hope that this willbe a simple question for you.

When some one starts dialysis for the first time can they go straight to NHHD (with the training as apropriate) or is it normal that they have to do some other form of dialysis frist? if it is the latter then how long is the first treatment duration before going to NHHD?

Thank you as always,


The short answer to your question, Shaymon, is … a definitive “yes”!

This is the ideal way to train to nocturnal home haemodialysis (NHHD). Indeed we have now trained a small number of patients straight in from CKD - though not nearly as many as we might have liked to, or could have … for the following reasons.

Obviously, the native AVF must have been fashioned well in advance. It must have had time to mature well and the vein wall must have had adequate time to ‘arterialize’ and toughen. In addition, there must be the logistic ‘matching’ of a new incoming trainee to an available training chair … sounds simple? … it isn’t!

I don’t know whether you have ever played Monopoly, but training directly into NHD is a bit like going ‘Directly to Go’ and 'Collect $100’ and bypassing the risk of ‘Go to Gaol’ and ‘Missing a Turn’ on the way round the board. I think, from recall, that in the game of Monopoly, the ‘Go + Collect’ option requires a ‘Chance’ card. In dialysis, it might be better named a ‘Reprieve’ card.

In our experience, either a young and/or under-developed, un-ready AVF and/or mismatched training to trainee logistics are the two most common issues that prevent direct training.

The first speaks for itself. While we have trained AVF-revision patients for temporary home-care with an IJ catheter to bridge their AVF repair down-time and, as well, have one permanent home patient on a catheter, a native AVF access at home (mostly but not all using buttons) is clearly (1) our goal and (2) our utter preference and (3) our almost 100% achievement.

If the AVF is not stable enough for early within-training self cannulation, we may allow (indeed we prefer) fistula stabilization in the satellite system for a few weeks before home training (though keeping this satellite-exposure-time as short as practical) – I think that that is the lesser of two evils … a short time in satellite care as against having the patient struggle with and/or fail at self cannulation due to an unready AVF. While the former is not ideal, but makes for a better home-assured outcome when compared to the shattering of confidence that may occur with the latter.

More commonly, though, the problem arises that the home training unit (HTU) is full. We now have a mean training time of 4-6 weeks but, some patients take longer, and no patient should be rushed beyond their own pace. If it takes 10-12 weeks to train – so be it! And, as we are taking and training patients well into their late 70s for HHD (our oldest is now, I think, 82) … NB: I do not believe age is a particular contraindication if all other capabilities, self-will and co-morbid health issues are not problematic. This has led to a rise in our mean training time from 3-4 weeks to more like 4-6 weeks. Achieving well-trained and safe HHD (and in our service this is always NHHD) is what matters, not the time it takes to get there.

But … this rise in training time, coupled now with a press of numbers - 1/3rd of all our HD patients in the home - has ‘strained’ our 4 station HTU. This is especially since our 1 respite chair out of 4 (3 x training chairs and 1 x respite chair) now looks more like a ratio of 2: 2. We prefer to ‘respite’ in our HTU rather than in the satellites, but this has put pressure on our capacity to train 3 at a time. This, in turn, can now and then (and unpredictably) create a backlog in training and which then, along with delayed AVF suitability, can stymie our goal of direct training.

These are really both logistic issues. Neither, in a perfect world, should exist. But patients do present late. Theatre time is at a premium and other surgery can be seen (by administrators and waiting-list clerks) as more urgent with AVF creation being ‘bumped’ in favour of other things. Some patients do need second stage procedures for superficialisation. Some patients do take longer to train and thus block the on-progress of others into training. Government funding is finite and may prevent the early opening or funding of additional training (or respite) chair capacity.

Finally, it is important to address and remember good, detailed, repetetive, preparatory pre-dialysis education. This cannot be achieved in a single session. Nor can it be achieved by a single educator. It must include the other family members or significant others who live with the trainee. It must involve the nephrologist and, preferrably, a dedicated pre-dialysis educator or equivalent. It should include both one-on-one and group education sessions and include meetings and unhurried discussion with the NHHD staff and with established NHHD patients. No patient should come to dialysis unprepared, unless due to either acute presentations or patient refusal to engage. A sound education program remains the key to successful home dialysis.

So … though the definitive and intentive answer to your question is “yes”, the reality answer is … ‘always – if we can and when the stars align’

Thank you for your reply Dr Agar

Kind regards