Home hemodialysis has clinical advantages in helping to meet Advancing American Kidney Health goals
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Efforts by HHS through the Advancing American Kidney Health to improve dialysis care has put home dialysis in the spotlight as a safer, alternative therapy, per advocates in a recently published study.
But home hemodialysis (HHD), now used by less than 2% of the country’s outpatient dialysis providers, may be a better option for patients contemplating the road home.
“In this article, we do not aim to pit HHD and PD in a battle of home dialysis superiority, as some observational studies have endeavored,” Robert Lockridge Jr., MD, and colleagues wrote. “Both HHD and PD have important roles. Nevertheless, considering the pathophysiology of contemporary dialysis patients and the aims of the Advancing American Kidney Health initiative, we contend that widespread availability of intensive HHD is a necessary ingredient in a successful system.”
Home hemodialysis has several advantages, particularly in managing volume and reducing right ventricular systolic pressure (RSVP), two issues seen in patients who die on dialysis, the authors wrote. “In many patients, successfully managing volume and reducing RVSP will require the completion of three objectives: 1) achievement of true dry weight; 2) an increase in weekly hours of kidney replacement therapy, thereby meeting cumulative ultrafiltration demand, but at an ultrafiltration rate that is sufficiently low to avoid intradialytic complications; and 3) an increase in frequency of therapy, thereby decreasing both peak RVSP during interdialytic gaps.
“These objectives are in reach with proper prescription of HHD, which is customizable to the individualized needs of patients,” they said.
If clinicians can bring blood pressure under control and see a reduction in primary and secondary left ventricular hypertrophy through the use of HHD, a “significant reduction” in the risks for cardiovascular death and hospitalization could occur, the authors said. “We also need to aim for symptom-free hemodialysis sessions, as numerous patients have loudly stated. Intensive HHD is one treatment that can address these needs.”
Increasing HHD use means patients need to hear about the modality and its benefits throughout their time on dialysis, the authors wrote. Methods of accomplishing that, the author wrote, include:
- Patients initiating dialysis can access a transitional care unit, which educates patients on all modalities;
- Prevalent hemodialysis patients “may participate in ‘trial run’ programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training,” the authors wrote. “In both models, perceived barriers to HHD, including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner, can be addressed in a supportive setting.”
- Peritoneal dialysis patients who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (ie, from peritoneal dialysis to HHD).
“Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of dialysis patients,” the authors concluded. “With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of dialysis patients.”
Perspective
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Paul Komenda, MD, MHA, FRCPC
The nephrology community has recognized for some time the dire need to shift how we care for patients requiring renal replacement therapy. Three times per-week hemodialysis in facilities scattered throughout the United States has been the standard of care for decades. This is the costliest form of dialysis for payers and has had terrible consequences for patients in terms of survival and unacceptably low health-related quality of life.
Advancing American Kidney Health (AAKH) has given hope that new policies may shift the attention to home dialysis. While peritoneal has been the primary home therapy, home hemodialysis (HHD) will need to be significantly ramped up to meet the ambitious targets set out by the AAKH. The roadmap to get these programs scaled up, however, remains unclear to many.
Lockridge and his co-authors are all thought leaders in the area of HHD in the United States, from both academia and industry. The systematic approach they describe in this paper to move more patients to HHD may serve as a useful blueprint for health systems and clinical programs alike in setting up meaningful structures in the promotion, uptake and maintenance of patients on this modality choice. Much of the discussion to date on increasing HHD has been aspirational and theoretical. Their attention to specific schedules and frameworks for transitional care units, trial run programs, educational initiatives to introduce HHD concepts and technologies, patient selection criteria and creating integrated programs for transitioning from peritoneal dialysis to HHD are to be applauded as critical elements of any health system seriously considering growing a robust HHD program built for the long term.
The care of our most vulnerable, frail patients on dialysis in the United States is in the midst of a significant reboot with the AAKH. It has the potential to educate and influence payers during a raging COVID-19 pandemic by convincing patients and providers to re-examine the benefits of home dialysis. There are very few advances in medicine that offer better clinical outcomes and superior quality of life at less cost to providers.
HHD checks all of these boxes. Concrete steps programs and health systems can take to achieve this for their patients are now available. There should be no more excuses to do better for our patients and the nephrology community as a whole.
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