Home dialysis options can assist in clinical decision-making
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With the prevalence of kidney disease expected to increase sharply in the next decade, the U.S. health care system is facing a significant challenge in how to care for these patients without further stressing an already beleaguered system. One idea that has gained traction is the prospect of shifting appropriately selected patients to home-based dialysis, either home hemodialysis or peritoneal dialysis.
The recently signed executive order from President Donald J. Trump creating Advancing American Kidney Health provides extra impetus. In addition to measures that seek to improve the availability of kidney transplants, the order establishes incentives to get more patients on home therapies, thereby offering to substantially increase the number of patients gaining access to and utilizing both home hemodialysis and PD. In furtherance of this goal, the order encourages private enterprises to work with the government to find and incorporate solutions.
Cost is one factor driving this trend. According to some metrics, as many as 37 million Americans are living with chronic kidney disease, although around 90% are unaware of their disease.1 Moreover, of the 661,000 Americans with kidney failure, about 468,000 patients are on dialysis.2 Despite that patients with ESRD within the Medicare population comprise less than 1% of beneficiaries, they account for an estimated 7.2% of total Medicare fee-for-service spending, totaling more than $35.4 billion.3
Meanwhile, home dialysis is associated with lower costs and better outcomes compared to in-facility hemodialysis.4,5 These figures suggest that wider adoption of home hemodialysis and PD have potential to save millions of dollars annually. Indeed, CMS has established an objective of getting 50% of patients with ESRD on home-based dialysis, with several private kidney care centers (such as Fresenius and DaVita) following suit with similar initiatives.
Advantages of home dialysis
Source: Stephen E. Hohmann, MD, FACS
Fundamentally, the push by the federal government and by both public option and private insurance entities are informed by the recognized patient benefits associated with home dialysis compared to in-center hemodialysis. Patients using home hemodialysis frequently have more profound improvements in blood pressure control, better kidney disease-related quality of life and shorter recovery time from dialysis treatments among other outcomes compared to similar patients on in-center dialysis.6 Similar benefits are associated with PD compared to in-center hemodialysis.7 Despite this, home hemodialysis and PD are underutilized options, with utilization rates of less than 2% for home hemodialysis and less than 10% for PD — figures that lag far behind those of other industrialized nations.7
In addition to the economic and clinical benefits, there are less tangible benefits of at-home dialysis that may be equally as important. For example, there is a psychological benefit for patients performing their treatment at home, where they are more comfortable and where they are not in a facility with other patients being reminded of their illness. Patients and their designated caregivers take greater ownership and responsibility of caring for the access site when they use at-home dialysis. Related to the former, with at-home dialysis, there is inherent consistency in who is performing the cannulation, whereas in a clinic setting, rotating work schedules and competing demands often dictate the need for different staff members to care for the same patient. Familiarity with the person helping with the dialysis is beneficial in many respects. Additionally, from the provider perspective, forming a partnership with the patient, who is ultimately the end user of the device, is more efficient and less confusing than discussing care directives with a third party.
The economic benefits associated with home dialysis are more so an additional benefit rather than the main thrust of why it is an important option to discuss with patients. It is imperative for physicians to be good stewards of health care resources and not unduly burden either the system or the patient with unnecessary expenses. In the final analysis, though, nephrologists are obligated to do what is best for the patient and in the case of at-home dialysis, it seems to be a better option that is cost-saving and cost-beneficial for patients and payers.
Home hemodialysis vs PD
An update to the conditions for coverage for dialysis issued by CMS in 2008 requires dialysis providers to inform patients about all their treatment options, including the availability of at-home dialysis when appropriate.8 Therefore, in some settings, taking time to have an informed conversation with patients serves their best interest and may ensure the clinic is in proper compliance with CMS guidelines. However, even if one takes the regulatory requirement out of the picture, there is inherent value in explaining all the options to patients.
Understandably, CMS is guided to a large extent by cost in encouraging home dialysis, and the differences between in-center vs. home dialysis vs. PD are certainly telling. Whereas in-center dialysis costs around $67,733 per beneficiary per plan year, PD costs Medicare roughly $48,796 per beneficiary per plan year. While there are not good data on the costs of home hemodialysis, PD is widely understood to be a less costly option.9 According to CMS, a 5% increase in utilization of PD instead of in-center hemodialysis could save as much as $295 million annually. One conclusion that can be drawn from CMS initiatives is it would prefer patients to be on home dialysis vs. in-center hemodialysis whenever appropriate, and when they are, PD would be the desired option.
There are some appreciable differences in the modalities that patients can use at home. The clinical implications of each have been described in the literature. In addition, there are factors related to quality of life that patients may find valuable to learn. For instance, PD is typically performed at night, which may be more convenient than home hemodialysis. The device used for PD is also smaller, which may allow patients more freedom to travel. However, there are some recognized drawbacks of PD, such as a sensation of fullness after dialysis.
In conversations with patients, it is important to share some the pros and cons associated with in-center and home-based hemodialysis. For example, hemodialysis is usually performed in 3.5- to 4-hour sessions, three times a week in in-center settings, and for shorter periods of time five to six times a week for home-based hemodialysis. There is some evidence the schedule associated with home hemodialysis may yield better long-term outcomes. Relative to PD, there is greater ability to adjust the amount of fluid removed from the body and to adjust electrolyte levels with hemodialysis. One common complaint with hemodialysis (either in-clinic or at-home) is patients feel good on non-dialysis days but can feel sick or tired on dialysis days. Of course, hemodialysis also requires placement of either an arteriovenous fistula (AVF) or graft (AVG), and access is gained with two needle sticks each and every time dialysis is performed. The inconvenience factor can quickly build up and lead to fatigue with the entire process.
Ultimately, the patient should make the final determination about what is best for their particular situation. Some may prefer to attend clinic visits, while others may opt for an at-home option. Truly, though, an element of control has been taken from these patients by virtue of their illness, and any way we can empower them to take back control of their situation is a tremendous gain.
Considerations
One of the frequently cited limitations to using peritoneal access is previous abdominal surgery and whether this should or might be a contraindication. Modern surgical techniques have helped to partially answer this problem. In many cases, any adhesions due to previous procedures can be repaired at the time of the catheter placement. If there is a limitation in this regard, it is that laparoscopy is required to identify adhesions, and it can be difficult to identify them during the surgical planning phase.
Advances in PD catheters have facilitated more streamlined implantation while also potentially giving patients better dialysis fluidic dynamics. There are systems designed to accommodate several implantations and tunneling techniques, including single-site incision. Catheters with a larger internal diameter (3.5 mm) compared to other on-market devices can be used, which allows for use of higher flow rates.
Within the realm of hemodialysis, there is ongoing debate regarding use of the AVF, which is widely considered the gold standard, or AVG. The controversy largely stems from the fact that although AVF is associated with less risk of infection, only about 50% mature without intervention. Furthermore, AVF non-maturation is associated with a higher probability of needing a central venous catheter, which may be associated with complications, while there is also evidence that assisted maturation may lead to suboptimal patency. Some have argued the potential for secondary procedures, coupled with the fact that an AVG does not require maturation before use, should prompt a rethink in the “fistula first” paradigm.
The new KDOQI guidelines for vascular access frame the discussion of access (AVF or AVG) nicely by considering a “ESKD life plan.” Rather than defaulting to an AVF, the patient specific circumstances should be taken into consideration. As a surgeon placing hemodialysis accesses, it is imperative to consider the goals and timeline needed for an access in addition to the patient’s anatomy and comorbidities. Rather than just being present, an access must support two needle dialysis at adequate flow rates to serve the patient appropriately. Rather than “fistula first,” it is patient first.
Conclusion
Many of the touch points in the ongoing conversation regarding how to best care for patients on dialysis are reflective of larger trends in medicine. Patients want to be involved in their care decisions and more so, they want to be empowered with education about their various options. Meanwhile, cost considerations are driving decision-making, which is sometimes, but not always, at odds with the idea of individualizing treatment choices. At times, care providers can feel caught in the middle of these competing demands.
At the same time, there is emerging evidence, beyond the ambitions of any public health initiative, that at-home dialysis confers advantages compared to in-center hemodialysis. Within the category, PD is arguably easier for patients than in-home hemodialysis. If the various options are presented fairly and honestly to each patient so he or she can decide based on their own circumstances, then nephrologists can be confident they are serving the best interest of patients.
- References:
- 1. CDC. Chronic Kidney Disease in the United States, 2019. Available at: www.cdc.gov/ kidneydisease/publications-resources/2019-national-facts.html. Accessed May 30, 2019.
- 2. National Institute of Diabetes and Digestive and Kidney Diseases. Kidney Disease Statistics for the United States. Available at: www.niddk.nih.gov/health-information/health-statistics/kidney-disease. Accessed May 30, 2019.
- 3. CMS. Comprehensive ESRD Care Model. Available at: https://innovation.cms.gov/initiatives/comprehensive-esrd-care/. Accessed May 30, 2019.
- 4. Walker RC et al. Clinicoecon Outcomes Res. 2017;doi:10.2147/CEOR.S69340.
- 5. Walker R. Nephrology (Carlton) 2014;doi:10.1111/nep.12269.
- 6. Tennankore K, et al. Nephrol Dial Transplant. 2014;doi:10.1093/ndt/gft383.
- 7. Chan CT et al. Am J Kidney Dis. 2019;doi:10.1053/j.ajkd.2018.09.015.
- 8. ESRD Program Interpretive Guidance: 42 CFR Part 494 Conditions for Coverage for ESRD Facilities. Baltimore: HHS, Center for Medicaid and State Operations/Survey & Certification Group, Ref: S&C-09-09, 2008.
- 9. Federal Register. Vol. 73, No. 73; April 15, 2008.
- For more information:
- Stephen E. Hohmann, MD, FACS, is a vascular surgeon and is with Texas Vascular Associates in Dallas.
Disclosure: Hohmann reports he is a consultant for Merit Medical.