Will Home Hemodialysis Ever Prosper in the United States?
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
References:
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.
Another major issue is the (dis)comfort of nephrologists with home therapies – both PD and HD. There is insufficient exposure to home modalities, both PD and home hemodialysis, during training. This leads to a default of in-center HD, reflecting how comfortable nephrologists are with the usual in-center HD routine as well as how easy it is, relative to home therapies, to start. And once patients start down a path and they’re doing OK, inertia takes hold and changing modalities becomes even harder. It will really take a shift of the entire culture, from practicing nephrologists to trainees to nurses, to change the knee-jerk reaction to initiate in-center hemodialysis.
thanks for these thoughtful remarks. As a faculty member in a division of Nephrology and a practicing Nephrologist, i fully understand where you are coming from, especially when there are severe time constraints on all your activities [as is now commonplace]. This, however, is not a good excuse to not try to emphasize any of the home modalities. perhaps, all nephrologists should have a professional staff member in their respective practices teach all the patients about the home modalities. Patient, physician and staff members in each practice should be educated also to the benefits of home modalities.
This is absolutely true. The focus on in center only HD has to be changed. More knowledge and comfort level of offering PD vs. home dialysis vs. palliative care has to increase.
We should not place conservative non-dialytic therapies in this context. The decision to ‘dialyze’ [whatever modality] versus conservative care of severe advanced ckd/esrd comes first. Part of the education process should include a stepwise decision tree. a] learn about ckd, b] learn about therapies, c] learn about dialysis modalities, d] leanr about conservative, e] learn about transplantation if appropriate, and f] prepare for dialysis with timely access if an hemodialytic modality is chosen. The RPA has a very neat guideline on the appropriate initiation and withholding and withdrawal from dialysis. lionel
Well I think there’s a lot more to this than Nephrologists preference for in center HD.
Up here, we have a fairly large PD program ( by US standards ) making up about a third of our some ~ 500 patients. We have about 7 patients on Nexstage.
Home therapy is a hard sell. HHD especially so. Even the conversation about being able to stay in their home villages and towns isn’t enough to convince patients.
As long as patients have a choice in modality selection in center will continue to dominate. The short sessions, socialization, the comfortable chairs, bedside computers and TV’s and flexible scheduling make it fairly appealing to a large number of patients,
The list of patient objections to PD despite intensive education, films, meetings, talking with other PD patients and the realization they will need relocate; is quite long and nothing new. Body image, every day, doing it themselves, EPO injections, storage space…..
Nexstage is even more difficult.The same objections as above plus many single or have unwilling partner. Very very few are willing to trade 3x per week to 5/6 despite assurances of better overall well being, better labs and less fluid restrictions.
I guess one could turn this around and ask why the obsession with pushing home therapies. The data favoring PD outcomes superior to in center are at best debatable.
Dear Dr. Tucker, “up here”, not sure, are you referring to Alaska per chance? I grew up in the Anchorage area at the top of O’Malley Road in the 1960’s. I respect your comments and I suspect that the difficulty selling home hemodialysis may in part be a cultural issue that is not that unexpected. Canada on the other hand has had better “luck” securing more home hemodialysis patients even in some remote areas. I am not sure I would call sitting in a dialysis a comfortable experience. I guess it depends on your perspective.
I much prefer the comfort of my own home as I am now doing with m NxStage. I wouldn’t call the NxStage that particularly difficult. If you can drive a car, you can easily learn all of the steps in doing home hemodialysis. Involved, yes. Difficult, no.
Lastly, the reason of for the push of home hemodialysis is two fold: Survival and cost containment. Despite the reluctance of the American nephrology community to accept the home hemodialysis modality, it is the preferred modality in several other nations and with good reason. PD does compare to standard in-center survival. On the other hand, many studies show that HHD compares to cadaveric transplant survival. (Pauly et al for instance 2009). Studies likewise show a clear cost benefit to home hemodialysis.
As a physician and a home hemodialysis patient, going home was a true no brainer for me after learning of all the different options. I would hope you don’t fatigue yourself on home dialysis options. They truly are the promise of the future of dialysis care in American and around the world.
Haven’t many surveys shown that home hemo [any form] or renal transplant as the therapy of choice for nephrologists should they develop esrd?
Wow! well said and agreed upon. I don’t believe our Nephrologist are stagnated, nor do I believe its a knowledge deficit with Nocturnal Home Hemodialysis. Studies clearly show not only decreased mortality. British Columbia raves of patient outcomes both Medically and physically. To make this shift in home vs facility hemodialysis wouldn’t it mean drastic changes in the ESRD system?
There are new studies namely the FHN trials: Home vs conventional incenter; and longer incenter vs conventional incenter. The latter is line with above two studies and their conclusion about better outcome has been observed. However when home dialysis vs compared to incenter HD, there was no benefit found despite longer treatments at home. Any thoughts?
I totally agree with Dr. Tucker re home dialysis. It is not a physician dependent problem. Most patients do not want to take the responsibility. We have to literally “beg” some of them to even consider it. Several problems: home water supply, compliance and motivation are major concerns
Dear Dr. Jhaveri, my old dialysis center added a home hemodialysis department a little over a year ago. I had urged my nephrology colleague to consider the advantages of home hemodialysis for many reasons since 2006. They have now shifted so many patients to the home hemo option in this one year that they have had to cut back on techs and nurses in the conventional unit and start recruiting patients. I would strongly advise that stating patients won’t do home hemodialylsis is biased and flawed. All it takes is a motivated nephrologist to have a thriving home hemodialysis program. It appears that is quite a rarity since most simply blame the patients.