product focus
Frequent home haemodialysis:
a review of the evidence
Although the care of people with renal conditions has improved, patients are now living long enough
to develop end-stage kidney disease and require dialysis. Frequent haemodialysis (FHD) has been
shown to be an effective treatment in many studies and trials. Sunita Nair discusses the evidence
surrounding FHD and the use of a portable, user-friendly machine, NxStage® System OneTM.
■  home haemodialysis  ■  chronic kidney failure  ■ incidence ■  treatment outcome  ■  survival rate
I
t is estimated that over 2 million patients
worldwide are affected by end-stage kidney
disease (ESKD) (Couser et al, 2011). An
increasing prevalence of diabetes and
hypertension, along with improved health-care
and survival, has resulted in an increasing number
of patients who are living long enough to develop
ESKD, requiring dialysis. This places a huge burden
on both service delivery and NHS finances.
Conventional thrice-weekly haemodialysis (HD) is
associated with significant mortality and morbidity,
and there is now a growing evidence base showing
medical, psychosocial and financial benefits with
more frequent dialysis (FHD) at home. Moreover,
given the constraints in dialysis facilities, FHD is
more feasible in a home setting, enabling schedule
flexibility and cost-effectiveness. This has led to
national directives dedicating efforts to increasing
the use of home HD (HHD); however, the global
uptake of this treatment remains rather dismal.
One of the key barriers to treatment with
HHD is patient fear (feeling overwhelmed using
complicated medical technologies), necessitating
the need for user-friendly technology (Cafazzo et
al, 2009). Although sophisticated, the traditional
dialysis machines are not easy to use; they are not
truly portable, and training staff and patients takes
much longer than newer technologies. However,
the advent of newer, smaller, effective and portable
machines, such as the NxStage System One (NxStage
Medical, Inc.), have helped to change the landscape
for patients undergoing HHD.
This article will review the evidence surrounding
the clinical, psychosocial and quality of life (QoL)
Sunita Nair
Consultant Nephrologist and Clinical Lead, Home
Dialysis Therapy, Shrewsbury and Telford NHS Trust
Email: sunita.nair@nhs.net
This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016
benefits of FHD, and discuss studies on treatment
outcomes following FHD at home with NxStage
System One.
Dialysis—past and present
In 1945, after 15 failed attempts, William Kolff,
the father of dialysis, conducted the first successful
HD in a 67-year-old female (Ing et al, 2012). The
invention of the Teflon shunt, 15 years later, saw
the emergence of HD as a treatment modality
for chronic renal failure (Blagg, 2005). With
improvement in the shunt technique, 1964 brought
about the use of dialysis at home in Boston, London
and Seattle. HD was initially conducted twice-weekly
for long hours, but later moved to thrice-weekly
(Blagg, 2005). This became the prototype for future
conventional in-centre dialysis schedules.
Since the 1960s, the increasing prevalence of
patients with ESKD, changing demographics, rises
in renal transplantation, changes in reimbursement
and the advent of alternative dialysis modalities,
such as peritoneal dialysis (PD), have resulted in
a decline in HHD and the emergence of centre-
based dialysis units. Thrice-weekly in-centre dialysis
for 4 hours per run became the norm.
However, more recently, improved general
medical care has paradoxically further increased the
prevalence of ESKD. Renal transplantation is often
not an option for the increasingly older group of
patients requiring renal replacement therapy (RRT),
and this, along with staff shortages, high mortality
seen with conventional haemodialysis (CHD), the
huge costs of setting up dialysis units, and evidence
showing advantages of HHD, have brought the focus
back to the provision of treatment at home.
© 2016 MA Healthcare Ltd
Incidence
The most recent annual report of the UK Renal
Registry (UKRR), which receives data from 71 adult
renal units across the UK, showed an increase in
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Home
haemodialysis
2.0%
Hospital haemodialysis
18.2%
Transplant
52.8%
Satelite
haemodialysis
20.8%
Continuous
Automated ambulatory
peritoneal peritoneal
dialysis dialysis
3.4% 2.7%
Figure 1.Treatment modality in prevalent renal replacement therapy patients
on 31 December 2014 (MacNeill et al, 2016)
incident dialysis patients from 109 per million
population in 2013 to 115 per million population in
2014 (MacNeill et al, 2016). The report states that,
as of 2014, 58 968 adult patients received RRT in the
UK. This was an absolute increase of 4% from the
previous year; the number of patients on HD, the
dominant modality, increased by 2% (MacNeill et
al, 2016).
Conventional haemodialysis
CHD consists of three HD sessions per week, with
each lasting from 3–4 hours in a dialysis facility,
either in a hospital or a satellite unit. Although
mortality has improved over the years, it is still
quite high in incident dialysis patients (Collins et
al, 2010). Despite advances in technology and better
understanding of ESKD, cardiovascular mortality in
patients receiving CHD especially after a 2-day gap
without tratment, which is now known as the ‘killer’
gap, remains significantly elevated (Bleyer et al 1999;
Fotheringham et al, 2015). This finding was also
corroborated by the Dialysis Outcomes and Practice
Patterns Study (DOPPS) (Zhang et al, 2012).
To overcome CHD-associated mortality, increased
dialysis dose, i.e. urea clearance, was suggested
(Eknoyan et al, 2002). However, in CHD, this failed
to improve clinical outcomes (Eknoyan et al, 2002),
and may reflect that increasing dialysis dose without
This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016
increasing treatment frequency does not necessarily
alter interdialytic fluid load.
Home haemodialysis
The National Service Framework for Long-Term
Conditions (Department of Health, 2005) states that
health professionals should become dramatically
better at involving patients and their carers, thereby
empowering them to manage and make decisions
about their own care and treatment. HHD offers a
unique opportunity to fulfil this mandate in ESKD
patients requiring dialysis, as it combines patient
benefits and cost-effectiveness. This treatment
regimen also allows patients to undergo more
frequent dialysis in their own home.
In 2002, the National Institute for Health and Care
Excellence (NICE) reported that 10–15% of dialysis
population would choose HHD therapies if offered
(NICE, 2002). Acting on the available evidence
and benefits, national policies are now aiming to
increase the use of HHD. Despite this, according to
the UKRR’s recent report, the uptake is rather poor
(Figure 1) (MacNeill et al, 2016).
Frequent home haemodialysis
With a view to improve dialysis outcomes, there has
been a revived interest in FHD, given that the longer
dialysis hours more closely mimic the fluid and
toxin removal performed by a healthy kidney.
FHD can be defined as a dialysis schedule that
offers more hours of dialysis per week, and aims
to eliminate the risks and side effects of CHD.
FHD can be undertaken as short daily HD (SDHD)
(five or more sessions per week, each lasting
about 2.5–3 hours), long frequent HD (five or more
sessions, each lasting >5.5 hours) and nocturnal
HD (NHD) (8 hours per run for 3, 4, 5 or 6 days
per week).
Due to staff shortages, lack of capacity in facility
units, and the huge financial implications in
developing more facility-based centres to meet ever-
increasing patient demands, it is more feasible for
FHD to be undertaken in a home setting.
Treatment outcomes with frequent
home haemodialysis: evidence review
Survival and mortality
FHD has been found to improve survival in dialysis
patients. Kjellstrand et al (2010) reported a 92%,
73% and 54% 1-, 3- and 8-year survival, respectively,
in a cohort of 262 SDHD patients. This was
© 2016 MA Healthcare Ltd
corroborated in an Australian study, with patients
mostly undergoing NHD (Jun et al, 2013).
In a matched cohort study, Pauly et al (2009)
compared survival in NHD patients with deceased
and living donor transplant patients. The study

showed no difference in adjusted survival between
the NHD and deceased donor groups. Pauly et
al (2010) then looked at patient and technique
survival in 247 NHD patients and reported an
overall 1- and 5-year survival rate of 95.2% and
80.1%, respectively.
Weinhandl et al (2012) found that, when
compared to HHD, a 13% lower risk for all-cause
mortality was seen in patients undergoing daily
HHD in an intention-to-treat design.
Cardiovascular events and hospitalisation
In a study that looked at all-cause and cause-
specific hospitalisation, it was found that the risk
of cardiovascular-related hospitalisation was lower
in the daily HHD group (Weinhandl et al, 2015).
The study also found a 15% (intention-to-treat)
and 25% (on treatment follow-up) lower risk of
hospitalisation for cerebrovascular disease.
SDHD and NHD improve left ventricular mass
index—an important predictor of cardiovascular
mortality and morbidity (Chan et al, 2002; Nesrallah
et al, 2003). This is in line with the findings from
a Canadian randomised controlled trial (RCT) in
NHD patients (Culleton et al, 2007). The Frequent
Haemodialysis Network (FHN) Daily Trial, which
looked at in-centre HD for six times per week vs
three times per week, also showed statistically
significant changes in left ventricular mass (FHN
Trial Group, 2010).
FHD also reduces blood pressure and the use of
antihypertensive medications. This has been studied
extensively and the findings are consistent. The
FHN Nocturnal Trial (Rocco et al, 2011) showed
improved blood pressure control in NHD patients, as
well as reduction in the number of antihypertensive
medications used. Moreover, in a retrospective study
by Kraus et al (2007), conversion from CHD to
SDHD resulted in improved blood pressure.
Mineral metabolism
Another consistent finding in patients undergoing
FHD regimens is better phosphate control. Multiple
RCTs and observational studies have shown a
decrease in serum phosphate levels, resulting in
reduced binder dosages. The FHN trials, which
looked at SDHD and NHD patients and phosphate
control, showed a reduction in the dose of binders
in the SDHD arm, while the NHD arm showed
discontinuation of binders in 75% of patients (FHN
Trial Group, 2010; Rocco et al, 2011). There was
© 2016 MA Healthcare Ltd
a reduction of 0.6 and 1.6 mg/dl in the levels of
serum phosphate with SDHD and NHD, respectively
(FHN Trial Group, 2010; Rocco et al, 2011). It is
the increased time on dialysis that results in the
phosphate reduction. This mitigates the need for
This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016
product focus
phosphate binders, the efficacy of which are often
reduced due to non-concordance with treatment.
The FREEDOM (Following Rehabilitation,
Economics and Everyday-Dialysis Outcome
Measurements) study, a prospective cohort study
looking into benefits of SDHD (six times per week)
reached similar conclusions (Jaber et al, 2010). A
Canadian RCT showed significant reduction in intact
parathyroid hormone in NHD (Walsh et al, 2010).
Quality of life
Improvement in physical and mental health-
related QoL has been reported in RCTs, as well
as prospective studies. The FHN trial reported
improvement in self-reported physical health in
the SDHD schedule compared with CHD (Hall et al,
2012). The FREEDOM study confirmed this further
in its SDHD patients (Finkelstein et al, 2012).
Restless leg syndrome
Restless leg syndrome (RLS), described as feeling
of achy and/or crawling sensations in the legs,
is experienced commonly by patients on HD.
Associations have been drawn between RLS
and depression (Tuncel et al, 2011), as well as
increased risk of cardiovascular events (La Manna
et al, 2011) and impaired QoL (Unruh et al, 2004).
The FREEDOM study showed improvement in
the prevalence and severity of RLS and sleep
disturbances in SDHD patients (Jaber et al, 2011).
Depression
Depressive symptoms, seen in about 35–40% of
dialysis patients, are associated with high risk
of withdrawal of dialysis and death (Lopes et al,
2002; Lacson et al, 2012). SDHD and NHD have
shown reduced Beck Depression Inventory scores
in the FHN trial (Unruh et al, 2013); although
the reduction was not statistically significant.
The FREEDOM study also identified a reduction
in depression prevalence from 25% to 16%
in 12 months in SDHD patients (Jaber et al, 2010).
Pregnancy
FHD with longer weekly hours has also been
associated with improvement in pregnancy-related
outcomes (Okundaye et al, 1998; Piccoli et al, 2015).
NxStage System One
One of the barriers identified in patient uptake of
HHD is the complex nature of traditional in-centre
dialysis machines. They can be intimidating at first
glance and are not particularly user-friendly for
patients and health professionals alike. Patients are
therefore reluctant to dialyse on these machines and
training times remain much longer.
 product focus
Figure 2. NxStage System One for home and travel
However, with the advent of newer, portable
HHD machines, such as NxStage System One, the
delivery of FHD is becoming an increasingly feasible
option for patients with ESKD. The Food and Drug
Administration approved this therapy system for
home use in 2004, in the US, and it was launched
in Europe in 2009. In the author’s opinion, NxStage
System One is a simple, elegant and efficient
portable system that is slowly revolutionising HHD.
Mechanism of action
NxStage System One comes in two forms: System
One with PureFlow SL, which generates dialysate
from a self-contained dialysate system, and pre-
This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016
packaged, 5 litre bags for portable use (Figure 2). The
bags are pre-filled and sterile, similar to PD fluids.
PureFlow SL generates ultrapure dialysate, meeting
the quality requirements of ISO 11663, in batches
of 40, 50 and 60 litres from concentrate, using tap
water. The tap water is purified by the integrated
deionising PureFlow system; ordinary water source
is exposed to a sediment filter and ultraviolet
light, after which it goes through the PureFlow SL
Purification PAK to generate ultrapure product water
(Figure 3). It converts source water into product water
at a ratio of approximately 1:1. There is also no need
for a disinfection protocol with chemicals.
Unlike conventional machines that use reverse
osmosis (RO), necessitating extensive plumbing
modifications at home, the NxStage System One,
due to its unique integrated system, only needs a tap
water connection. The ultrapure dialysate formed
can be used for up to 120 hours. It has a lactate
buffer and, in slight deviation from traditional
solutions, has a limited option of electrolyte
composition. Frequent low-volume dialysis does not
result in significant changes in serum electrolytes,
and therefore this ceases to be a limitation.
In contrast to traditional machines, the NxStage
System One, similar to PD, consists of a single-use,
pre-packaged cartridge, with blood, dialysate and
saline infusion lines contained in the cartridge
(Figure 4). This prevents any direct contact of blood
or dialysate with the cycler. The cartridge comes with
or without a pre-attached gamma-sterilised dialyser
membrane. Since it is pre-packaged and for single
use, the wipe down time is significantly minimised.
Adequate and effective dialysis
Near saturation for the dialysate with uraemic
solutes is required to provide adequate effective
dialysis. Unlike traditional machines, which improve
urea clearance by increasing either dialysate or
blood flow rate, NxStage System One works on the
principle of using a low dialysis flow rate, which
is achieved by maintaining a low ratio of dialysate
(QD) to blood flow rate (QB), also called the flow
fraction (QD/QB) (Figure 5).
When prescribing conventional in-center HD,
the constraint is to deliver a maximised dialysis
dose in a limited time, using high dialysate flow
and volume. With FHD, the challenge is to limit
the volume of dialysate to be produced or delivered
at home. Optimising the saturation of dialysate at
home, up to 90%, during more frequent short or
© 2016 MA Healthcare Ltd
long treatments, makes it feasible. This low-volume
dialysate principle, which is the hallmark of NxStage
System One, results in less waste, thereby reducing
costs of water and electricity, while improving
dialysis efficiency.
 product focus

Interim product Final product

water quality water quality
resistivity monitor resistivity monitor
QUALITY OF TAP
WATER MAY VARY 0.2 micron Ultra Pure

Source water Sterilising Product

grade filter

Carbon media filter

(ordinary water

Mixed bed DI resin

Dual bed DI resin

Dual bed DI resin

Dual bed DI resin

Ultrafilter

Ultrafilter
Sediment filter

tap water)
Protects against touch
Ultra violet light contamination and
provides redundancy
■ Bacterial
control Removes
bacteria and
■ Breaksdown endotoxins
chlorine and VALIDATED
Removes large chloramines Reduces MEDICAL GRADE
particles organics, ■ Removes ionic solids, ■ Polishers for WATER
chlorine, colloidal aluminium ionics
chloramines
■ Kills bacteria through ■ Reserves DI
and heavy
metals pH shifts capacity

Figure 3. PureFlow SL Purification Pack (PAK)

Training times Certain risks are unique to the home setting.

With simplicity at its core, NxStage System One Treatments at home are done without the presence
is very user-friendly. This has had a significant of medical personnel and on-site technical support.
impact on training times, which otherwise Patients and their partners therefore must be trained
remain much longer. The European multicentre on what to do and how to get medical or technical
study, KIHDNEy (Knowledge to Improve Home help if needed.
Haemodialysis Network in Europe), which Risks associated with HD are also increased when
looked at experiences with NxStage System One, performing NHD due to the length of treatment time
showed that the mean training time was much and because therapy is performed while the patient
shorter (16.9 sessions) when compared with and care partner are sleeping. These risks include,
conventional machines (27.7 sessions) used in the but are not limited to, blood access disconnects and
FHN trial (Pipkin et al, 2010). blood loss during sleep, blood clotting due to slower
blood flow or increased treatment time or both, and
Meeting the criteria delayed response to alarms when waking from sleep.
NxStage System One is an effective, portable Patients should consult with their physician to
machine for HHD in patients who have a stable understand the risks and responsibilities associated
vascular access, can maintain high standards with home NHD using the NxStage System One.
of personal hygiene and have a partner, as
recommended in the manufacturer’s criteria. Evidence base
With this new system, HHD is now a viable option There is now increasing evidence showing clinical
for most patients who are committed to being benefits with the use of NxStage therapy systems in
trained and following the guidelines for proper patients undergoing HHD.
system operation. The reported benefits of HHD may In a multicentre, prospective, open-label,
not be experienced by all patients, but only a few 2-month crossover feasibility study, Kraus et al
medical conditions may prevent a patient to be a (2007) compared home- and centre-based treatment
candidate for this treatment, such as psychiatric or with NxStage System One and concluded that it was
mental health conditions. a viable dialysis option for patients capable of HHD.

Treatment-related risks Figure 4. Disposable single-use cartridge with blood,

NxStage System One is a prescription device and, like dialysate and saline infusion lines
all medical devices, involves some risks. The risks
associated with HD in any environment include,
but are not limited to, high blood pressure, fluid
overload, low blood pressure, heart-related issues and
vascular access complications. The medical devices
used in HD therapies may also add additional risks,
such as air entering the bloodstream, and blood loss
© 2016 MA Healthcare Ltd

due to clotting or accidental disconnection of the

blood tubing set. Patients should consult with health
professionals overseeing their care to understand the
risks and responsibilities of HHD and/or FHD using
NxStage System One.

This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016
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Case studies
600 The following case studies not only point towards
Qb=300 the benefits of FHD, but also break the perceived
Qb=400 myths about the suitability criteria of patients.
Qb=500
500 Qb=600
Case study 1: 60-year-old male
A 60-year-old man with a history of ESKD secondary
/P)
(D to anti-glomerular basement membrane disease was
400 n
tio maintained on in-centre HD for 8 years. He was
Urea clearance (ml/min)

ra
satu
te
lysa
300 dia
NxStage therapy %
00
(Qd=approximately 1/3xQb) 1
200
Conventional dialysis
(Qd=2–3xQb)
100
0
0 100 200 300 400
Dialysate flow rate (ml/min)
Figure 5. Urea clearance with increasing dialysate flow rates: NxStage approach vs
conventional dialysis (data reproduced with permission from NxStage Medical, Inc.)
Kohn et al (2010), in a single-centre feasibility study,
concluded that the six-times-per-week schedule
using NxStage System One was equally effective as
CHD in the removal of metabolic wastes, i.e. urea
and phosphorus, as well as middle molecules, such
as beta-2 microglobulin (Kohn et al, 2010).
Modest survival benefits were reported in the
SDHD group when compared to CHD in a matched
cohort retrospective study of 11 228 patients
(Weinhandl et al, 2012). In a later matched cohort
study comparing clinical outcomes on daily HHD
with PD, Weinhandl et al (2016) concluded that
there was a 20% lower risk for all-cause mortality
and a 8% lower risk for hospitalisation in the HHD
group compared to PD (Weinhandl et al, 2016).
Following FHD, the FREEDOM study
demonstrated improved benefits in physical and
mental QoL and reduction in depressive symptoms,
as well as an improvement in the severity and
frequency of RLS (Jaber et al, 2010; Tuncel et
al, 2011).
Brahmbhatt et al (2016), in a case report,
deemed unsuitable for a renal transplant as he had
cardiomyopathy. During one of the author’s unit
rounds, she discussed HHD with him, particularly
ND in view of his cardiomyopathy. He showed keen
interest in NxStage System One and was trained in
its use. This was considered inappropriate by some
staff, due to the long-held belief that someone
with a ‘weak heart’ cannot be dialysed at home.
Nevertheless, he trained well and the team was able
to establish him on HHD using the machine. He
dialysed for 5 months with no untoward incidents.
Unfortunately, he was diagnosed with metastatic
500 600 cancer during this time and after much discussion
about treatment options, he decided to withdraw
dialysis. The palliative team became involved in
his care and the gentleman died peacefully at
home surrounded by his family. His last words to
me were: ‘Thank you for persevering and training
me to go onto HHD. After spending 8 years in
hospital, I am glad I have had the opportunity to
dialyse at home, and spend some quality time with
my family.’ These emotions cannot be quantified
in any studies, but underline the importance of
what it means for patients to dialyse at home. Case
studies such as this one also break the long-held
belief that kidney care professioanls need to cherry-
pick patients for HHD.
Case study 2: 30-year-old female
A 30-year-old female developed ESKD secondary
to meningococcal septicaemia and commenced on
in-centre HD. She was very non-compliant, with
significant issues surrounding hyperphosphataemia
that was uncontrolled. Deemed as a ‘difficult
patient’, she had burned all of her bridges with
nurses, dietitians and physicians. However, after
the NxStage team held an awareness programme at
the author’s trust, the patient came forward with a
request to go on HHD.
Although there was a unanimous belief among
staff that the patient simply could not go onto HHD,
given her history the author had a long discussion
© 2016 MA Healthcare Ltd

described a successful pregnancy and delivery in a
29-year-old African American female with ESKD.
She conceived after 3 years of receiving HD with
NxStage System One and successfully delivered a
1.93 kg baby at 33 weeks (Brahmbhatt et al, 2016).
with her about what it entailed. Given her history
of non-compliance, it was agreed that some ground
rules would be set by way of a contract, which has
now been adopted as routine practice, suggesting
that should she display persistent non-compliance,

This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016

then we would have no option but to switch her
back to in-centre HD.
Given her interest in the treatment and the fact
that HHD would be highly beneficial, the author
decided to put her on the list for training and she
did very well. Within 6 months of her being home,
her phosphate levels were down to near normal.
Her behaviour towards staff improved significantly
and she seems much happier in herself. She was
also one of the volunteers who participated in the
NxStage campervan programme, where patients were
dialysing in a campervan parked in the trust’s car
park. This campaign was undertaken with a view to
improve HHD awareness.
The patient has come a long way, not only
showing significant improvement in her metabolic
profile, but also improvement from a psychosocial
point of view. The author believes this is due to the
trust that was placed in her, giving her a sense of
control over her life, which otherwise seemed to be
totally taken over by her dialysis. She now remains
on the waiting list for a transplant.
Case study 3: 76-year-old male
This patient was a 76-year-old man with history
of ESKD secondary to diabetic nephropathy. He
also has a history of macular degeneration, and
was awaiting eye surgery when his renal functions
plummeted and needed dialysis. He was offered
hospital HD, presuming he would not be a suitable
candidate for home therapy given his partial
blindness. When he met the author for the first time
in clinic along with his wife, HHD was discussed and
he was keen to be trained.
Along with his wife, he undertook training on
the NxStage machine and underwent eye surgeries
during this time. His vision was slowly improving
and with the help of his wife and fantastic training
from the team, he was soon established at home.
The patient and his wife are frequently touring in
their motorvan round the country. NxStage has
made it possible for them to be able to holiday in
their van and carry on dialysis. He was also one of
the volunteers for the campervan programme, which
served as a rehearsal for their planned holiday.
The couple, who were initially looking to a life of
being in hospital three times a week and felt their
life was totally restricted, could not be happier. In
the patient’s words: ‘This is the future of dialysis.’
Incorporating NxStage System One
into patient treatment plans
© 2016 MA Healthcare Ltd
In the author’s experience, the introduction of
NxStage One has definitely generated more interest
in FHD from staff and patients alike. The trust
has been able to redevelop the home therapies
This article is reprinted from the journal of kidney care  vol 1  no 3  September 2016
product focus
programme by having a dedicated consultant and
a nurse lead, along with a team of nurses doing PD
and HHD under one umbrella of home therapy. A
multidisciplinary dedicated clinic for these patients,
a dedicated training room and a facility for in-centre
respite further enhances modality retention.
However, clinicians must bear in mind that many
of the benefits described with NxStage System One
were in studies supported by the manufacturer,
which leaves some room for bias in reporting
outcomes. There is also no study showing a head-
to-head comparison between NxStage System One
and traditional HD machines at home; however,
there is enough evidence to suggest that the former
is as equally effective and safe for use in HHD as the
traditional machines.
Overall, there are several key advantages with
NxStage System One compared with traditional
machines. The training time is much shorter, the
machine requires minimal modifications at home,
and it is truly portable and uses less space. This,
combined with less wasted water, reduces the initial
installation cost, which is quite high with the use of
traditional machines at home.
Conclusion
Living life on a machine is tough, and brings with
it a whole host of physical, emotional and social
changes for patients’ lives. It is therefore incumbent
on the kidney care community to be able to deliver
safe, simple, treatment with good sustainable clinical
and psychosocial outcomes in a cost-effective
manner. FHD, which is more feasible at home,
provides improved outcomes and is in line with
national service framework recommendations.
There is a growing body of evidence that
empowers health professionals to deliver FHD
using NxStage System One, which is an intuitive,
effective, portable system with a simple patient-
machine interface capable of delivery of variable
treatment options. These qualities, along with the
limited requirement for modifications to home,
reduced training time, improved biochemical and
psychosocial outcomes, makes NxStage System One
a cost-effective option.
The KIHDNEy study has shown some encouraging
preliminary data; however, further studies and RCTs
are required to explore FHD and other risk benefits
further. Until then, clinicians have an effective
option to provide clinically beneficial FHD for a
larger range of patients at home. 
Conflict of interest: The publication of this article was
supported by NxStage Medical, Inc. Sunita Nair is a
member of the NxStage European Medical Board.
product focus
References
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Successful pregnancy using the NxStage home
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