Six years of experience with nightly home hemodialysis access

Lynchburg Nephrology Dialysis Incorporated started its nightly home hemodialysis (NHHD) program in September 1997.

The purpose of this study was to evaluate episodes of exit-site infections, catheter sepsis, and safety and longevity of accesses for patients doing NHHD.

If internal jugular (IJ) catheter was chosen, the patient was started on 2 mg coumadin per day when catheter was placed. If catheter malfunctioned, it was blocked with a thrombolytic agent and coumadin was adjusted to meet a goal international normalized ratio (INR) of 1.5 to 2.25. If the problem persisted, the catheter was exchanged. For catheters, a threaded lock cannula (BD InterLink device, BD) was used to prevent air emboli and infections and a locking device was used to prevent disconnects. If arteriovenous (AV) fistula was used, four buttonholes were established using 16-gauge needles. If AV graft was used, patients were taught the rope ladder cannulation technique using 16-gauge needles.

As of September 1, 2003, 45 patients have completed training and have performed 27,063 treatments at home. Total catheter time at home was 930 months. Total AV fistula and AV graft times at home were 190 and 20 months, respectively. Upon completion of training, 34 patients were using tunneled IJ catheters, 10 were using AV fistulas, and 1 was using an AV graft. The IJ catheter exit-site and sepsis infection rates were 0.35 and 0.52 episodes per 1000 patient-days, respectively. Mean catheter life was 8.5 months with the longest being 66.7 months and the shortest being 0.2 months. The AV fistula and graft exit-site and sepsis infection rates were 0.16 and 0 episodes per 1000 patient-days, respectively. Catheter complications included one episode of disconnect due to patient's failure to use the locking device, one episode of central stenosis, and one episode of intracranial hemorrhage, due to prolonged INR, with resolution of symptoms.

Data support the fact that tunneled IJ catheters, AV fistulas, and AV grafts are effective and safe permanent accesses for patients on NHHD.