Technology, more education can move home dialysis to the next level
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Osman Khawar, MD, remembers the home dialysis machines he worked with during his nephrology training at Harbor-UCLA Medical Center.
“These were big, hefty machines,” Khawar, now a member of Balboa Nephrology in San Diego, told Nephrology News & Issues. “They were workhorses, built for reliability and power.”
Today, technology has streamlined home dialysis machines. Starting with the SystemOne from NxStage Medical, approved by the FDA in 2005 for home hemodialysis, other machines from Outset Medical – approved for home dialysis last year – and companies like Quanta Medical and DEKA Research & Development Corp./CVS, both pursuing clinical trials with their machines, home dialysis has become more user friendly for patients.
Source: Mike Sleva
But the technology still needs improvement, Khawar said. As CEO of Diality Inc., the nephrologist said he hopes the company will seek FDA 510(k) device clearance next year for its home dialysis machine and then begin trials with patients soon thereafter.
“We see two perspectives in the home dialysis market,” Khawar said. “For the patient, we see this as a consumer product. That means it needs to be easy to use, offer an interface that provides timely feedback and a seamless connection, and safety measures so patients feel they are being take care of.
“For providers, a machine also needs to offer the nephrologist a full spectrum of easy-to-use prescription options based on individual patient needs. It must also have a good feedback mechanism for prospective patient data,” Khawar said.
Jeff Burbank, chief strategy and transformation officer for Fresenius Medical Care North America, said home dialysis cannot take the next step into the mainstream without including improvements in technology.
“We should think of internet access as equally important for a patient’s success on home dialysis as prescribing iron supplements or a phosphate binder,” Burbank, the former CEO for NxStage Medical, told Nephrology News & Issues. “We must not allow financial barriers to get in the way of connected health technologies to improve patient quality of care. While studies have clearly demonstrated that use of connected health is improving lives, limitations on access to technology, tech literacy and financial stability must be eradicated.”
The technology divide is greater for certain populations in the United States, he said. “A recent study from the Pew Research Center shows that while 80% of white adults report having a broadband connection at home, that number drops to 71% for Black adults and 65% for Hispanic adults,” Burbank said. “Among Americans 65 years of age and older, only 61% own a smartphone or have broadband internet access.”
Interest in home hemodialysis
Most of the research and development work in home dialysis is focused on devices for hemodialysis despite peritoneal dialysis dominating the market.
“I think most of these companies see hemodialysis as the long-term modality optiion for home,” Robert Lockridge, MD, a nephrologist from Lynchburg, Virginia, told Nephrology News & Issues. “Peritoneal dialysis is a great first therapy, especially for urgent starts when patients still have residual renal function. Hemodialysis can be the next step for patients who want to stay at home.”
Lockridge recently co-chaired a day-long symposium sponsored by the International Society of Hemodialysis that evaluated new technology for home hemodialysis (a recording of the program is available at www.ishd.org).
One of the new home hemodialysis machines featured during the program was the S³, developed by the French company Physidia. It has been used to treat over 1,000 patients in Europe and is built for short daily hemodialysis, Lockridge said. The machine was approved in France in 2013, and launched in Europe in 2017.
Like Lockridge, Brent Miller, MD, a professor of medicine at Indiana University Health, said technology is what manufacturers should focus on in developing a home dialysis machine. “They must be easy to use – that is the key for patients,” Miller told Nephrology News & Issues.
Miller remains a major advocate for nocturnal home hemodialysis, a therapy similar to continuous cycling peritoneal dialysis (CCPD) in terms of overnight dialysis but not required every night like CCPD.
“I think it is a niche,” Miller, who has managed patients on nocturnal dialysis for more than 20 years, told Nephrology News & Issues. “But we have a whole generation of nephrologists who haven’t heard about it.
“Clearly, from a biological and physiological aspect, it is the best therapy we have; however, the therapy is not scalable or practical. Better technology to manage an overnight therapy and a comprehensive support system are lacking. If we can fix those two things, I think nocturnal dialysis takes off,” Miller said.
A prescription for nocturnal dialysis can be every other night for many patients with residual renal function or up to 5 nights a week for those with comorbidities, such as heart disease, Miller said.
Patient education
Education for patients who are in the early to middle stages of kidney disease should include discussion about modalities. But Lisa Koester Wiedemann, CS, MSN, ANP, CNN-NP, a renal nurse practitioner at Washington University School of Medicine in St. Louis, said educators should focus on the bigger picture of end-stage kidney disease first.
“I have faced skeptics who think educating patients at CKD stage 3 is too early,” Koester Wiedemann told Nephrology News & Issues. “But I remind them that it’s not just educating patients about modalities. It is about reminding them of getting their blood pressure checked. We ask them to watch their diabetes and what they are doing about exercise. We ask them to watch their salt intake.
“Once they have these addressed and are comfortable with those issues, patients will be better informed about how to decide on renal replacement therapy options.
“Patient education takes time. It’s not one session and you are done. But if you wait too long, it will be a knee-jerk reaction on modality choice.”
- For more information:
- Jeff Burbank is the chief strategy and transformation officer for Fresenius Medical Care North America. He can be reached at jeffrey.burbank@fmc-na.com.
- Osman Khawar, MD, is a member of the Balboa Nephrology Medical Group in San Diego and is CEO of Diality Inc. He can be reached at okhawar@diality.com.
- Lisa Koester Wiedemann, CS, MSN, ANP, CNN-NP, is a renal nurse practitioner in the division of nephrology at Washington University School of Medicine in St. Louis. She is also a member of the Editorial Advisory Board for Nephrology News & Issues. She can be reached at lkoester@wustl.edu.
- Robert Lockridge, MD, is associated with Lynchburg Nephrology in Lynchburg, Virginia. He can be reached at boblockridge@gmail.com.
- Brent Miller, MD, is the Michael A. Kraus Home Dialysis Professor of Nephrology and professor of clinical medicine at Indiana University Health in Indianapolis. He is also a member of the editorial advisory board for Nephrology News & Issues.
He can be reached at bwm1@iu.edu.
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