Home hemodialysis: A glass half full

The language we use can be a powerful tool. While a glass holds the same volume whether it is half full or half empty, there is a world of associative difference––in optimism or in pessimism––that accompanies these two opposing viewpoints of the same glass.

And so it is with home hemodialysis. The negativism and pessimism generated by interminable discussion of "delivery barriers" for providers could easily bubble with optimism for and opportunities in a therapy that empowers, frees and lifts life restrictions for our patients, were we to simply change our language.

Yet, all we ever hear or read about are these barriers. Even those who ardently support home hemodialysis seem to be mired in "barriers" ––unthinkingly shooting themselves in the foot with negativism even as they seek to promote the “brand."

Rather, let us begin to talk of opportunities.

Empowering patients

There is an opportunity to empower patients, who have been cocooned in our protective care as if they are somehow incapable of self-care or self-determination. Yet, as dialysis physicians and nurses, that is exactly what we say we would choose for ourselves: self-care, self-determination and, being at home! In a survey of Scottish nephrologists, 94% would elect home therapy for themselves, with more than 80% choosing hemodialysis over peritoneal dialysis.¹ Yet, similar to the U.S. pattern of home vs. in-center dialysis, 95% of Scottish patients dialyze at a center. Similar preference choices have been reported from nephrologists in Canada, Australia, and New Zealand.

By enabling home-based, self-scheduled, long, slow, gentle, and overnight treatment in the safety of the patients' own home, dialysis sessions can be lengthened, slowing volume removal, and improving the clearance of deeper compartments and more complex, middle molecular toxins.² At home, sessional frequency can also easily increase to, at the least, alternate nightly care, thus eliminating in the blink of an eye the life-style brutality and actual mortality associated with the so-caller "killer weekend." ³

The opportunity to enable re-engagement––for patient and carer alike––with the self-esteem and financial benefits that accrue from a return to work as the freedom to self-regulate the dialysis schedule permits dialysis to be delivered in the time and at the convenience of the patient, and not of the center. In addition, let us not forget that dialysis first developed in the United States and around the world as a (largely) home-based therapy. ⁴

There is an opportunity to save significant health care dollars for both the local provider and the global health care program by providing and encouraging a treatment conclusively linked to lower global costs.⁵ It also offers the opportunity to halt the proliferation of the costly dialysis "stores" that now seem to occupy every suburban corner. The opportunity to build and bolster home support systems, while being mindful that patient home-based self-determination and not service imposition in the home, is the primary goal.

While there are clearly challenges to be met – particularly in home training practices and in home support systems – the opportunity to develop these wisely and in a planned way should be met with enthusiasm. In New Zealand and Australia, home hemodialysis is a gold standard therapy, with many dialysis programs sustaining 25%-30% or more of their hemodialysis patients at home. Those who dialyze at home emerge as more content, compliant, and contributory– a far cry from the depersonalizing mass production line that characterizes so many center-based programs.

If we believe, as I do, that home hemodialysis is optimal dialysis, then we must talk no more of "barriers." Such talk simply devalues the very therapy that we profess to value so much. We must change our glass half empty attitude to home care. Rather, we should view home hemodialysis as a glass half full, just waiting to be topped up to the brim.

References

McManus SK, Mactier RA. Scottish nephrologists’ dialysis preferences: exposing the gap between what we offer and what we would choose. http://www.slideshare.net/ringer21/1-scottish-nephrologists-dialysis-preferences-exposing-the (last accessed 7th March, 2013.)

Eloot S, Van Biesen W, Dhondt A, Van de Wynkele H, Glorieus G, Verdonck P, Vanholder R. Impact of hemodialysis duration on the removal or uremic retention solutes. Kidney Int. (2008). 73(6): 765-70.

Zhang H, Schaubel DE, Kalbfleisch JD, Bragg-Gresham JL et al. Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality. Kidney Int. (2012). 81: 1108-1115.

Blagg CR. A brief history of home hemodialysis. Adv Ren Replace Ther. (1996) 3(2): 99-105.

McFarlane P, Komenda P. Economic considerations in frequent home hemodialysis. Semin Dial. (2011). 24(6): 678-83.