Staff assistance, improved technology are key for home dialysis to succeed
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There is no one-size-fits-all treatment plan for chronic kidney disease.
However, due to advances in home hemodialysis and peritoneal dialysis, qualified patients who are properly prepared and supported throughout home-based care can achieve greater quality of life at lower cost compared with conventional in-center hemodialysis (ICHD).
Patient education
When it comes to patient education and preparation for initiating home care modalities, timing is key. Preparing too early places unnecessary fear in patients who may not need dialysis for many years and whose clinical status may change. Starting education too late limits options for patient decision-making and leads to an increase in suboptimal starts. That can lead to patients being placed on ICHD who may have otherwise been a good fit for PD or HHD.
Nephrologists can now use well validated tools to determine which patients are at highest risk for progression of CKD to kidney failure during a 2-year period. The kidney failure risk equation uses patients’ eGFR, urinary albumin: creatinine ratio (uACR), age and sex to determine which patients are at higher risk of progression toward end-stage kidney failure. These patients should be followed more intensively, and this tool can be used as an indicator for when providers should start in depth multidisciplinary education about treatment modalities.
Mortality risk
A 2021 study found patients who experienced failure with HHD showed a “significant” increase in mortality following a switch to facility-based HD. While the mechanisms of failure are technically unknown, patients likely stop HHD due to medical reasons or frailty.
Instead of switching to ICHD – which has inherent risks and challenges that have been exacerbated since the onset of the COVID-19 pandemic – providers should consider ways to better assist patients at home. The value in doing so is apparent: HHD is not only preferred by many patients but can alleviate costs, discomfort and patient indignity.
Though HHD has been shown to provide superior quality of life and has equal or lower mortality rates, it is not always the best treatment modality for patients with CKD. HHD requires an upfront investment that includes training patients to self-administer care. This can take anywhere from 4 to 6 weeks.
It is also important to keep in mind that patients may be reticent to self-administer care without the support of a provider or caregiver. For patients who cannot or are too anxious to self-administer care confidently but are still good candidates for home-based therapy, PD should be considered.
PD to transplant
PD followed by transplant is a viable treatment option for many patients with CKD, but there remain nuances to this modality. Some patients encounter medical or social reasons that they are not able to carry on with PD. For instance, patients who experience an adverse event, such as a stroke, may no longer be able to provide for themselves effectively at home, or the availability or ability of a caregiver may have changed. Some patients on PD may simply no longer be successful due to loss of their residual kidney function. In cases like these, keeping patients on PD at all costs is not encouraged.
Currently, staff-assisted home care is not possible for many patients with dialysis and their providers due to structural and economic barriers, but this must change. Home assistance can provide a buffer for patients who are initially too nervous to self-administer treatment, eventually giving them the confidence and familiarity needed to succeed in home-based therapy.
For staff-assisted, home-based dialysis care to succeed, every effort must be made to holistically support patients, addressing the economic, physical and emotional barriers that currently exist to home-based care. We owe it to our patients to use the technologies and human capital available to improve their outcomes and quality of life.
- For more information:
- Paul Komenda, MD, FRCPC, MHA, FACP, is an epidemiologist and professor of medicine at the University of Manitoba and research director of the Chronic Disease Innovation Centre in Winnipeg, Canada. He is also a member of the Editorial Advisory Board for Nephrology News & Issues. He can be reached at paulkomenda@yahoo.com.
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