Home Hemodialysis: Thoughts from a Practicing Nephrologist

“It is much more important to know what sort of a patient has a disease than what sort of disease the patient has.”

— Sir William Osler

What do our patients with ESRD want? They want to stay alive, to feel well, to be autonomous and to continue to be valued by their family and community. To achieve these goals, dialysis in the home, whether by peritoneal dialysis (PD) or by home hemodialysis, remains the best option for many. Why then does the percentage of home patients remain stubbornly low, and where does home hemodialysis fit in?

Although the answer to this question is multifaceted, the community of nephrologists must first look in the mirror and accept the brunt of responsibility. The choice of dialysis modality requires the managing nephrologist to be proactive, creative, and to firmly believe in the patient’s ability and right to make his own informed choice. Being proactive means believing that dialysis options provided by trained personnel (not the time-constrained nephrologist) are an essential part of management, even for those patients who land in the hospital with ESRD and invariably find themselves in-center with a central venous catheter.

We must advise, but not dictate, what is right for any individual. Being proactive also means forcing yourself to become competent and comfortable with PD and home hemodialysis, despite any prior deficiencies in training. It means demanding that your dialysis provider create a competent home program and if they do not, that you send the patient elsewhere. It means not relinquishing decisions regarding what is best for your patient and the community to large dialysis organizations, intermediaries, and the Centers for Medicare & Medicaid Services (CMS). As practicing nephrologists, we must act in the best interests of our patients.

This proactive and creative spirit needs to extend to making home hemodialysis an option for our patients. Although successful home hemodialysis dates back to the beginning of renal replacement therapy, rapid technological advances have made this a more viable option. Confusion and hesitancy by practicing nephrologists is understandable, but this needs to be a challenge that we undertake—and eventually overcome.

Making sense of the emerging literature is difficult, especially related to the wide range of dialysis prescriptions being assessed (number of treatments, nocturnal vs. short daily home dialysis, etc.), the small sample sizes, and the nuances of dialysis dose related to available machines (e.g., NxStage). Many of us were never exposed to home hemodialysis patients during training and are unfamiliar with current technology. These challenges can be overcome, just as happened in the early days of PD or in-center hemodialysis. The key to success in home hemodialysis (and PD) is a well run home program, the scarcity of which is likely the greatest impediment for most nephrologists. What is more difficult is the threat of CMS intermediaries effectively squashing this modality in its infancy by making it economically non-viable. The recent communications from Noridian (https://med.noridianmedicare.com/web/jeb/policies/coverage-articles/hemodialysis-frequency) and other intermediaries regarding reimbursement of additional treatments had a chilling effect on those who deliver this modality.

Will home hemodialysis fulfill the need to increase value in the care of ESRD? That is, will it increase quality of care while being cost-effective? The jury is out on this question as it is for many of our interventions.

The Frequency of Dialysis Network data supports the possible quality benefits of additional treatments (1), but how does that endorsement apply to the NxStage machine, where clearance rates are lower? Recent data suggest that hospitalization rates for Medicare patients on home hemodialysis are equivalent to those for in-center hemodialysis, calling into question the promise of reduced total cost of care (2). Admissions for septicemia were higher for home hemodialysis, whereas those for heart failure were lower. Patient selection is likely a large modifier of the value equation for home hemodialysis. Review of the past 8 years of our experience suggests that the home hemodialysis population we serve is not reflective of the general dialysis population; it is divided into healthy individuals wanting to continue busy work schedules and extremely sick patients who have failed in-center (e.g., owing to persistent hypotension, congestive heart failure, or inability to travel to the dialysis unit).

The question of value related to home hemodialysis will require larger clinical trials and more in-depth analysis of current practices. As with all areas of medicine, the answer to this question is a moving target related to rapid technological advances and greater understanding of what is needed to support the patient at home. The improvement of survival over the past decade for PD has exceeded that for in-center hemodialysis perhaps in part owing to better home dialysis programs (3). Similar advances are likely to occur for home hemodialysis.

Addressing the questions of quality and cost-effectiveness in a rigorous fashion is our obligation. It is also the obligation of CMS and its intermediaries to not put undue economic barriers on innovation. For those on the ground, including physicians, facility personnel, and patients, there is little doubt that home hemodialysis has a role to play in the management of ESRD. What most patients want is to live, not just to stay alive. To achieve this goal, we as nephrologists must be creative and proactive.

References

1. 

The FHN Trial Group. In-center hemodialysis six times per week versus three times per week. N Engl J Med 2010; 363: 2287–2300. http://www.nejm.org/doi/full/10.1056/NEJMoa1001593

2. 

Weinhandl, ED, et al. Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. Am J Kidney Dis; 2015, 65:98. http://www.ajkd.org/article/S0272-6386%2814%2900973-1/abstract

3. 

Schaubel, DE, et al. Effect of renal center characteristic on mortality and technique failure on peritoneal dialysis. Kidney Int 2001; 60:1517. http://www.nature.com/ki/journal/v60/n4/abs/4492573a.html