Characteristics and Organization of In-Center Nocturnal Hemodialysis in the Netherlands: Practical Guidance for Centers Willing to Initiate Nocturnal Hemodialysis.

Introduction: Nocturnal in-center hemodialysis (HD) offers a higher dialysis dose and longer ultrafiltration time than regular HD, which potentially benefits at least a selection of patients. Currently, only a minority of HD patients have access to in-center nocturnal HD. Many practical and logistical problems must be overcome by an HD center before the treatment can become operational.

Methods: For assessing the detailed organization of in-center nocturnal HD in the Netherlands, an observational cross-sectional study was performed using Nefrodata (Dutch Registry of dialysis patients) and structured questionnaires for center managers and nephrologists. Descriptive analyses were performed, followed by an analysis of best practices.

Findings: Out of 55 Dutch dialysis centers, 27 offer in-center nocturnal HD, treating 255 out of 5200 patients treated with intermittent HD. Of these 27 centers, 4 stopped providing in-center nocturnal HD, mostly due to organizational problems. Our survey showed that some aspects of treatment were similar in the various centers, such as duration of sessions (7-8 h), patient education at the pre-dialysis outpatient department, treatment prescription, and blood pressure monitoring. In contrast, patient selection varied between centers, for example, regarding functional vascular access: non-tunneled catheters were not allowed during in-center nocturnal HD in some centers. Also, hemodynamic instability observed during daytime treatment was, by some centers, considered a problem for starting in-center nocturnal HD. Furthermore, large differences regarding the organization of nursing staff exist. Importantly, all nephrologists agree that in-center nocturnal HD is a useful part of the treatment repertoire offered in their centers.

Discussion: Practical guidance to organize a successful and safe in-center nocturnal HD program is provided. Patients' safety should be guaranteed without affecting the patient's night's sleep. In-center nocturnal HD offers patients the most optimal metabolic control, excellent intradialytic hemodynamic stability, and volume control with more free time during the day.