Patient training, connective technology, skilled staff are key in home dialysis retention
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Dialysis at home dates to the 1960s, yet teaching continues today about training and supporting patients who select the modality option and helping them stay at home, kidney specialists told Healio | Nephrology News & Issues.
Photo courtesy of Jamie Uribarri, MD
“Starting patients on home dialysis – and helping them stay at home – does rely on education done right in [chromic kidney disease] CKD and during home training and follow-up,” Lisa Koester-Wiedemann, ANP, CNN-NP, a renal nurse practitioner in the division of nephrology at Washington University School of Medicine at St. Louis, told Healio | Nephrology News & Issues. “Education cannot stop with just home training. Education is ongoing through the patient’s journey at home.”
Sixty years ago, few hospitals had established kidney treatment centers, so home therapy was the standard to treat end-stage kidney disease. More hospital programs were established but in 1970, 40% of patients were still doing hemodialysis at home, Madhuri Ramakrishnan, MD, a nephrology fellow at Washington University School of Medicine in St. Louis, wrote in an article in 2019 for the Renal Fellow Network. “The rate of decline in-home hemodialysis in subsequent years was quite dramatic. Less than 15% of patients on dialysis were on home hemodialysis by 1978, falling to less than 5% by 1980,” he wrote.
Home dialysis, both peritoneal dialysis and HHD, have slowly increased during the last 25 years as reimbursement and device technology have improved. According to the U.S. Renal Data System, approximately 14% of patients with ESKD performed dialysis at home at the end of 2021.
Patient selection
While increasing new starts is key to expanding use of home dialysis — a key component of the End-Stage Renal Disease Treatment Choices model funded by CMS — advocates also want to help patients continue with home therapy because of the benefits.
“Home dialysis discontinuation can seem like yet another clinical outcome that we measure, study and even tie to financial consequences for health care providers,” Eric D. Weinhandl, PhD, MS, vice president of epidemiology at DaVita Clinical Research, told Healio | Nephrology News & Issues. “But at the end of each home dialysis ‘journey’ is a patient who is likely feeling ill and sad. Many patients who transition from PD to in-center HD describe a sense of grieving over their loss.”
With proper support, most patients can be good candidates for home therapy, Mihran Naljayan, MD, MHA, FASN, FNKF, chief medical officer for home modalities and pediatrics at DaVita Kidney Care, told Healio | Nephrology News & Issues.
“Patients can be successful at home, even with significant comorbidities or disabilities and even without the assistance of in-home care partners,” Naljayan said. “Often, the patients with the strongest desire to treat at home are most successful. Patient engagement paired with the support of a home care team are large drivers of success.”
Home therapy is also a driving force for value-based care programs.“Home dialysis offers significant quality of life improvements for many patients, including fewer dietary restrictions, fewer side effects and increased engagement in their health care,” Jessica Demaline, MSW, senior vice president of health care operations at Interwell Health, told Healio | Nephrology News & Issues. “Nationally, we are seeing steady increases every year in both people choosing to start dialysis at home, in retaining people at home and even in shifting more patients to home within 1 year after onset of kidney failure.”
In the first half of 2023, almost 30% of patients in Interwell’s government value-based care programs started dialysis at home, Demaline said. “We know that when patients are educated about their disease and treatment options, they feel more empowered and confident to choose home dialysis,” Demaline said.
Nupur Gupta, MD, an assistant professor of clinical medicine at Indiana University School of Medicine and medical director for DaVita Home Dialysis of Indianapolis, told Healio | Nephrology News & Issues that the benefits of home therapy can help patients succeed.
“Both [PD and HHD] therapy modalities have their benefits and are an option for the right patient,” Gupta said. “PD provides an opportunity for patients to experience the benefits of home dialysis while they may transition to HHD eventually. The majority of patients perform PD with independently or minimal assistance, while HHD may require more support.”
Weinhandl said U.S. Renal System data show variations among patients who transition from home dialysis to in-center care. “With PD, there is little trend over time. After 2 years, roughly 25% of patients have converted to in-center HD,” Weinhandl said. “Rates of conversion from PD to in-center HD are higher among Black patients, those who are younger age, patients with diabetes as the cause of the ESKD and [those who have] greater social deprivation.
“Smaller home programs also have higher dropout rates,” Weinhandl said.
Beginning around 2014, the incidence of conversion from home HD to in-center HD decreased, Weinhandl said. “Among patients who started HHD in 2019 to 2020, only 21% had converted to in-center after 2 years. Risk factors for premature conversion are generally similar to those in PD,” he said.
Program success
Brent W. Miller, MD, the Michael A. Kraus Professor of Clinical Medicine at Indiana University School of Medicine, told Healio | Nephrology News & Issues that providing patient support and managing home programs to produce good outcomes can be challenging.
“Managing home dialysis patients and many chronic illnesses is intensive, hard work,” Miller said. “Our dialysis corporate structure, physician education, CMS reimbursement and large health system administration are not well-developed to handle this. The dialysis nursing crisis with the pandemic was a major blow to home dialysis.
“We have not made the therapy easier in the last 5 to 6 years [for patients],” he said. “The FDA is still too expensive, time-consuming and difficult to innovate in a small treatment area of 600,000 people, of which maybe 30% can do home therapy.”
Home dialysis programs seeking to identify patients with ESKD who are a good fit for starting and remaining on home dialysis can look for certain characteristics, Koester-Wiedermann and other kidney specialists agreed.
Regarding trends seen in the St. Louis program, Koester-Wiedemann said a lack of family support and limited expertise from the in-center dialysis clinic managing the home program can hurt retention.“If the clinic does not have seasoned nurses and nephrologists who can think outside of the box, be flexible with prescribing and recognizing that the patient and care partner are struggling at home” the program will lose patients, Koester-Wiedemann said. “Clear expectations at the onset of home dialysis – our patients tell me early on to be honest about how much time home dialysis takes, not to sugar coat anything about it – can improve the chances of success for the home program,” she said.
“Physicians play a significant role in helping to instill trust and inspire their patients, despite comorbid conditions or other environmental factors that might be perceived as obstacles,” Naljayan said. “As a community, we continue to push on existing beliefs about what an ‘ideal home patient’ might look like to unlock the benefits of the modality for even more patients.”
Koester-Wiedemann said training patients the right way helps with retention. “Don’t skimp on training. There is this notion to get patients out of training early – why? Training provides more support for the patient and their care partners.
“Having a defined training plan allows patients to fully understand upfront what training will look like. Assess your patient before training – go to their home, involve care partners and understand what type of ‘learner’ they are. This will help with training. And don’t train patients when they are uremic – this never works,” she said.
Connective technology
Home dialysis staff can track patient use of home therapies remotely via connective technology and identify potential problems earlier. “Remote patient monitoring (RPM) platforms enable health care providers to securely view their patient’s treatment data, while remotely adjusting prescriptions,” Jaime Uribarri, MD, a professor of medicine and nephrology at Icahn School of Medicine at Mount Sinai, told Healio | Nephrology News & Issues. “There are already several studies in the literature that have demonstrated that the use of RPM is associated with lower PD discontinuation rates, treatment adherence, blood pressure control, ultrafiltration control, reduction of hospitalizations, reduced health costs and improvement in patient-reported quality of life,” Uribarri said.
Uribarri uses Baxter’s Sharesource platform in his PD program. “Sharesource allows easy connectivity with the patient’s cycler at home and gives the care provider the ability to assess ongoing progress every day as well as changing prescription from a distance. Individual treatment data available to providers includes patients’ vital signs, prescribed PD treatment, actual treatment length, individual cycle fill volumes, ultrafiltration volumes as well as fill, dwell and drain times,” Uribarri said.
In a poster presented at ASN Kidney Week in 2023, researchers led by Francisco Javier Centellas Pérez, MD, of the Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain, showed that the Sharesource software helped to reduce technique failure among patients on automated PD. The multicenter cohort study included 232 patients in 16 hospitals, and RPM was used in 176 of the patients. In a second group, 56 patients were treated with automated PD and without RPM.
Before propensity score matching, APD with RPM (n=176) vs. without RPM (n=56) was associated with lower mortality and better technique survival. After propensity score matching, APD with RPM continued to associate with better technique survival.
“The use of an RPM program in [automated] PD patients may be associated with better technique survival,” Centellas Pérez and colleagues wrote.
“These new data help us further understand the essential role digital capabilities play in helping kidney patients stay on home dialysis longer and the potential to support more sustainable care options,” Peter Rutherford, MB, BS, PhD, head of global medical affairs for kidney care at Baxter, told Healio | Nephrology News & Issues.
Naljayan said more than half of DaVita patients on PD and more than 85% of patients on HHD are on a connected cycler.“This means our nurses have access to their treatments in almost real time,” Naljayan said. “In addition, through DaVita Care Connect, our patient-facing application, patients can message their nurse directly, join telehealth visits, view educational materials and view their lab results,” Naljayan said.
Staff-assisted dialysis
Kidney specialists interviewed for this article had mixed views on whether staff-assisted home dialysis could help patients stay with the therapy.“There is a lot of exploration underway to determine the potential impact of staff assistance,” Naljayan said. “A few examples where staff assist is being explored include assistance for patients as they begin treatment at home; short-term support for patients following a hospitalization or stay in a skilled nursing facility; and interim help for patients who rely on a care partner, enabling that partner to take a respite,” he said.
Gupta said there is a benefit for patients. “It would provide opportunities to patients with limited support and especially if [they are] transitioning from the rehabilitation center or hospital,” she said. “In [my] personal experience, many patients are not able to do home dialysis as they don’t want to burden their families. Staff-assisted is an opportunity for these patients.”
“I think that time-limited staff-assisted home dialysis could be a tremendous asset in helping patients, and especially their care partners, get through the rough patches of the home dialysis journey,” Weinhandl said. “Truly, it’s like respite care, but without a change in dialysis setting.”
Changes needed
Miller said infrastructure and services for home dialysis programs still need improvement before better outcomes can occur. “Vascular access is a big barrier for HHD,” Miller said. “Making this easier is critical. I think the ‘lowest hanging fruit’ in this area is point-of-care ultrasound.
“Personalization of the treatment is also the next step,” Miller said. “The ability to adjust dialysate concentration for both PD and HHD with every treatment would be valuable. Also, more monitoring of the patient daily — how we package that to help the individual patient is a big opportunity.”
The path to improved home dialysis programs and long-term retention lies in the hands of advocates of the modality, Weinhandl said. “People with kidney failure have lives filled with relationships and goals. Life does not revolve around Kt/V, despite what the quality measure industrial complex might argue.
“We need to identify patients’ goals, and then build home programs that support those goals,” Weinhandl said. “Home dialysis care plans that maximize the quantity and quality of ‘dialysis-free time’ will attract the interest of plenty of patients.”
- References:
- Centellas Pérez J, et al. SA-PO654. Presented at: ASN Kidney Week; Nov. 2-5, 2023; Philadelphia.
- Ramakrishnan M. Home hemodialysis: A thing of the past, a lesser known reality of our present, or a promise of the future? https://www.renalfellow.org/2019/05/06/home-hemodialysis-a-thing-of-the-past-a-lesser-known-reality-of-our-present-or-a-promise-of-the-future/. Published May 6, 2019. Accessed Jan. 22, 2024.
- United States Renal Data System. 2023 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md. 2023. https://usrds-adr.niddk.nih.gov/2023/end-stage-renal-disease/2-home-dialysis. Accessed Jan. 22, 2024.
- For more information:
- Jessica Demaline, MSW, can be reached at jessica.demaline@interwellhealth.com.
- Nupur Gupta, MD, can be reached at nugupta@iu.edu.
- Brent W. Miller, MD, can be reached at bwm1@iu.edu.
- Mihran Naljayan, MD, MHA, FASN, FNKF, can be reached at mihran.naljayan@davita.com.
- Jaime Uribarri, MD, can be reached at jaime.uribarri@mountsinai.org.
- Eric D. Weinhandl, PhD, MS, can be reached at wein0205@umn.edu.
- Lisa Koester-Wiedemann, ANP, CNN-NP, can be reached at lkoester@wustl.edu.
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