Unlock the full potential of home hemodialysis with a goal-driven approach
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The nephrology community is navigating an evolving landscape of kidney care transformation. Nephrologists and kidney care teams are reconsidering how to prescribe therapy to patients with end-stage kidney disease as the United States works toward the monumental goal of 80% of incident ESKD patients receiving a kidney transplant or undergoing home dialysis by 2025 as outlined in the Advancing American Kidney Health initiative.
Even with the advent of emerging technologies, novel care models and new regulatory frameworks, patients remain at the forefront of care. As care delivery ventures into new territory, the opportunity arises to reevaluate the potential of home dialysis, specifically home hemodialysis, through the lens of goal-oriented medical care.
Treatment for patients with ESKD should include high-quality care achieving symptom relief and disease-driven solutions while being patient-centered and goal-oriented. This mind shift in perspective recognizes that the patient’s needs and goals should be at the forefront of treatment decisions, thus expanding the pool of potential options, including HHD.
While an increasing number of patients are receiving home dialysis in the United States, HHD remains underutilized. Latest data from the U.S. Renal Data System Annual Report include the following:
- From 2011 to 2021, the percentage of incident patients on home dialysis increased from 7.5% to 13.4%. However, only 0.4% started with HHD.
- Between 2011 and 2021, home dialysis among new and preexisting patients increased by 45%, from 9.7% to 14.1% of patients. However, HHD increased from 1.5% to 2.3%.
Studies have shown that most patients are not presented with the option of HHD when starting dialysis. Many nephrologists recognize that HHD can lead to better outcomes, especially if patients undergo more frequent therapy, and a better quality of life for patients, but misconceptions still prevail among the kidney care community that prevent higher adoption rates. For some, concerns about patient training, technical complexities and patient responsibility outweigh the potential benefits of doing treatments at home. This mindset leads to many physicians turning to conventional treatments as the default.
Patient-centricity in HHD
Prioritizing the clinical and personal needs and goals of patients is not just an adjustment in philosophy. It is a practical approach that can translate to more patients choosing and successfully undergoing HHD. The Standardized Outcomes in Nephrology studies emphasize daily life realities, like fatigue and life participation, as core outcomes on the same level as cardiovascular disease and mortality. Home dialysis allows for more individualization of patient treatment plans. Recognizing and understanding the specific needs of each patient should be the foundation for prescribing treatments for patients with ESKD.
Patients want to ensure that their prescribed dialysis treatments fit within their desired well-being and lifestyle goals. For example, the patient’s daily routine, including work schedule and family responsibilities, at-home support system and desire to travel, become part of the modality choice in dialysis therapy. Taking their needs into account can help ensure patient compliance and enhance satisfaction with their dialysis treatment. A patient-centered strategy not only encourages good outcomes for individuals but also contributes to the success of dialysis programs overall and encourages progress toward reaching the U.S. goal of more home dialysis penetration.
Goal-oriented approach
The International Society for Peritoneal Dialysis endorsed a patient-centered, goal-directed prescription approach in 2020 with guidelines for prescribing peritoneal dialysis PD. The key recommendation was to establish “shared decision-making between the person doing PD and the care team” with the aim of achieving the patient’s own life goals. The nephrology community can leverage and adapt these existing practice guidelines for HHD, implementing a goal-directed strategy for prescriptions.
Two quotes from patients mentioned during national advisory boards events in the last 10 years —“I just want to remain as active as possible;” and “I want to live a life as normal as possible with dialysis” — exemplify the expectations of goal-centric, individualized dialysis care. And yet, not everyone dependent on dialysis will achieve this goal.
I participated in the investigational device exemption study for FDA clearance of the NxStage System One in 2005 and witnessed people living a full life again with more frequent HHD. They thrived by finishing a college degree, getting married, being employed again, living in retirement fulfilling one’s hobby, becoming engaged in family life, traveling with a recreational vehicle and seeing grandchildren grow up.
Future developments
HHD was the dominant kidney replacement therapy at the beginning of dialysis until the early 1970s. In the last 2 decades, HHD has reemerged and more than 30 million patient treatments later has become a dependable, practical solution rather than a theoretical technology. Continued innovations rooted in robust clinical evidence and patient and health care provider feedback, including additional indications allowing for flexibility, have allowed home dialysis and patients to thrive.
Future developments in kidney replacement therapies, such as advancements in transplantation, integration of artificial intelligence and implantable devices, point to the potential for even more individualization in patient care.
Meanwhile, the kidney care community has the opportunity and responsibility to act for the benefit of our patients by rethinking our collective approach to dialysis prescriptions.
Embracing HHD as an instrumental piece of a goal-oriented care delivery strategy aligns with the broader goals of greater home dialysis uptake and individualized patient-centric kidney care. Implementing this approach requires changes in attitude toward HHD, strong collaboration with patients through shared decision-making and continued innovations to improve HHD.
In the broader kidney care picture, prioritizing patient needs remains the “North Star” for all stakeholders. This commitment to patients is the secret ingredient that transforms good intentions into tangible improvements, charting a course for improved clinical outcomes and enhanced quality of life for patients with ESKD.
- References:
- Brown E, et al. Peri Dial Int.2020;doi:0000-0002-4453-6486.
- Fluck R, et al. BMC Nephrol.2014; doi:10.1186/1471-2369-15-16.
- https://www.healio.com/news/nephrology/ 20190710/trump-executive-order-pushes-for-80-of-eskd-patients-to-have-transplant-or- be-on-home-dialysis-by-20.
- Home dialysis highlights. 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. https://usrds-adr.niddk.nih.gov/2023/end-stage-renal-disease/2-home-dialysis. Published Oct. 31, 2023. Accessed Dec. 19, 2023.
- Manera K, et al. Am J Kidney Dis.2020;doi:10.1053/j.ajkd.2019.09.017.
- Mehrotra R, et al. Kidney Int.2005;doi:10.1111/j.1523-1755.2005.00453.
- Urquhart-Secord R, et al. Am J Kidney Dis. 2016:doi:10.1053/j.ajkd.2016.02.037.
- For more information:
- Brigitte Schiller, MD, FACP, FASN, is senior vice president and medical officer of Fresenius Medical Care Home Therapies. She is also a member of the Editorial Advisory Board for Healio | Nephrology News & Issues. She can be reached at brigitte.schiller@freseniusmedicalcare.com.
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