Invited Commentary by Dr. Lionel Mailloux
It is interesting to note the two recent articles in the American Journal of Kidney Diseases on the topic of home hemodialysis. One was by Marshall et al entitled “Home Hemodialysis and Mortality Risk in Australia and New Zealand Populations”, and the other was a special review article “Systematic Barriers to the Effective Delivery of Home Dialysis in the United States: A Report From the Public Policy/Advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis ” by Golper et al.
Home dialysis modalities are markedly underutilized in the United States compared with several other countries. There are many reasons for this, and Golper et al outlines numerous systematic barriers to the effective utilization of home hemodialysis. The authors acknowledge these must be addressed at many levels, not the least of which is governmental.
On the other hand, Marshall et al analyze the ANZDATA registry and present many interesting conclusions. They note that both conventional home hemodialysis and frequent extended home hemodialysis modalities often offer a survival benefit compared with in-center hemodialysis and peritoneal dialysis. It should be noted that the home dialysis populations were younger and had fewer comorbidities. Analysis of the ANZDATA also demonstrated that late referral to the nephrologist increased mortality risk. This study clearly confirms what had previously been described in small comparative studies from the 1990s with older dialysis practices and less statistical strength that there is a lower mortality for home hemodialysis patients compared to either in-center hemodialysis or peritoneal dialysis. It is very assuring to know that home hemodialysis, whether it is conventional or frequent extended therapies, offers a survival benefit to patients undertaking this rigorous treatment protocol.
Realizing the survival benefit with decreased mortality makes the subsequent article by Golper et al more compelling and timely to address the under-utilization of these therapies. It is interesting to note that many patients are not aware of the home hemodialysis options. This will require aggressive education of patients with advanced chronic kidney disease so they can make appropriate choices when they require renal replacement therapy. Also important is the targeting of primary care physicians to ensure that patients are referred to nephrologists in a timely manner. This will allow better education of patients about chronic kidney disease and renal replacement therapy options. Earlier patient referral to nephrologists will avoid the “acute ESRD presentations” that ultimately lead to limited discussion of modalities. The nephrologists and the dialysis staff also need to understand the benefits of home hemodialysis so they can appropriately counsel patients.
Overall, these are 2 articles that should be kept as reference pieces and referred to on a frequent basis when counseling patients and educating peers.
Lionel U. Mailloux, MD, FACP
Clinical Professor of Medicine, Hofstra North Shore-LIJ School of Medicine
Former Member, Board of Directors, Renal Physicians Association
Marshall MR, et al. Home hemodialysis and mortality risk in Australia and New Zealand populations. Am J Kid Disease. 2011;58(5):782-793.
Golper TA, et al. Systematic barriers to the effective delivery of home dialysis in the United States: a report from the public policy/advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis. Am J Kid Disease. 2011;58(6)879-885.