All Patients Should Have the Opportunity for Home Dialysis . . .

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Few chronic diseases require the patient commitment and lifestyle alterations that end stage renal disease does. Patients on dialysis have significant dietary restrictions and require a multitude of medications. In-center hemodialysis (HD) schedules are inflexible and require time commitments in excess of 12 hours per week. The inflexibility of in-center HD clearly affects the ability of patients to care for sick children and spouses, work, go to school, and greatly limits their ability to travel.

Chronic kidney disease requiring dialysis not only impacts patient morbidity and mortality but also overall satisfaction with care and quality of life. With this in mind, we need to more closely examine opportunities that may improve our dialysis patients’ quality of life. Home dialysis is one such opportunity. Although patients without treatment partners may have physical impairments that exclude them from home dialysis, low educational level or nonadherence to in-center HD should not disqualify them as candidates for home therapies.

There is no clear difference in mortality among patients on in-center HD, peritoneal dialysis (PD), and home HD, so patient preference should dictate the modality of treatment. One of the major barriers to home dialysis is education—or lack thereof—regarding home therapies. Many patients just beginning dialysis have not had prior care by a nephrologist. These patients start HD in the hospital and are not educated about the possibility of home therapies. Many of them continue in-center HD unaware that home dialysis is a possibility. It is important to discuss home therapies with patients already receiving in-center HD. In our centers, we discuss home dialysis opportunities with patients during dialysis rounds. In addition, nurses from the home training department provide quarterly home dialysis education programs in the lobby of our dialysis units.

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Education regarding opportunities for dialysis at home is crucial. Patients who are more informed about home dialysis tend to choose PD over in-center HD. PD patients report improved satisfaction with their overall care and believe that their treatment has less impact on their lives than do in-center HD patients. PD patients also report feeling better and having increased independence and flexibility in treatment schedules (1,2). One of the key factors in treatment satisfaction is patient choice. Those patients who are informed and actively involved in medical decision-making are more likely to adhere to their treatment and thus gain the full benefit of the therapy (3,4).

Home HD patients report similar improvements in quality of life, including improved depression scores and improved recovery time following HD (5). Heidenheim et al. reported that patients on home HD experienced such great improvement that they would continue the therapy even if it were proven to shorten their survival (6). In-center HD patients often experience side effects of large volume shifts such as excessive thirst, pre-dialysis dyspnea, intradialytic hypotension, and cramping. It is not surprising that patients prefer dialysis options that limit these large volume shifts.

Our approach is to allow all patients who wish to attempt home dialysis a trial of therapy, provided they are deemed competent by the home dialysis staff and that they attend and complete training. Patients who have been “difficult” in-center HD patients often do very well as home dialysis patients provided they are motivated to “go home.” In our clinic, we have seen patients who seek a second opinion regarding home dialysis because they have been denied that option elsewhere. They have been told that because their blood pressure is poorly controlled or their phosphorus is too high, they must not be adhering to their treatment and medication schedules. Or they have been told their body mass index is too high or they are too old. Likewise, we have seen patients who wish to do home HD denied that opportunity because they have a dialysis catheter and not an arteriovenous access. Patients who seek second opinions regarding their suitability for home dialysis are highly motivated and typically do very well at home.

With the continued increase in the cost of health care, providers must strive to be good stewards of the health-care dollar. Educating patients and providing them support to “go home” is one such opportunity. According to 2006 data from the U.S. Renal Data System, Medicare expenditures per patient-year were $18,562 less for PD than HD. Annual per patient cost of PD was $53,327 versus $71,889 for HD (7). Although there are still relatively limited data regarding short-daily HD, it appears that the increased cost of treatments may be offset by decreases in medication and hospitalization costs (8). An in-center HD patient who misses treatments has a much greater impact on the dialysis unit than a home dialysis patient, given staffing requirements, reuse, and the possibility that someone else could be using the empty treatment chair.

Not every dialysis patient should be a home dialysis patient. Even among those patients who receive pre-dialysis education, most still choose in-center HD. The important point is that each patient be able to choose the treatment modality that is right for him or her. Even for those patients who fail a home therapy, it is important that they had the opportunity to try.

Although we cannot change the time commitments and the lifestyle alterations required of end stage renal disease patients, we can provide education regarding the available treatment opportunities. If we were the patient, we would expect no less than to have the opportunity to choose the type of care that best suits our needs.

References

1. 

Chisholm MA: Enhancing transplant patients’ adherence to medication therapy. Clin Transplant 2002; 16:30–8.

2. 

Loghman-Adham M: Medication noncompliance in patients with chronic disease: issues in dialysis and renal transplantation. Am J Manag Care 2003; 9:155–71.

3. 

Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A, and Finkelstein FO: Hemodialysis and peritoneal dialysis: patients’ assessment of their satisfaction with therapy and the impact of the therapy on their lives. Clin J Am Soc Nephrol 2006; 1:1191–6.

4. 

Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, and Powe NR: Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. J Am Med Assoc 2004; 291:697–703.

5. 

Finkelstein F, Collins A, Glickman J, Hull A, Kraus M, McCarthy J, Miller B, Spry L, Jaber B: Daily home HD (DHD) improves quality of life (QoL) measures, depressive symptoms and recovery time: interim results from the FREEDOM study [Abstract]. J Am Soc Nephrol 2008; 19:52A.

6. 

Heidenheim AP, Muirhead N, Moist L, and Lindsay RM: Patient quality of life on quotidian hemodialysis. Am J Kidney Dis 2003; 42:36–41.

7. 

U.S. Renal Data System, USRDS 2008 Annual Data Report:Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2008; 178.

8. 

Kumar VA, Ledezma ML, Idroos ML, Burchette RJ, and Rasgon SA: Hospitalization rates in daily home hemodialysis versus peritoneal dialysis patients in the United States. Am J Kidney Dis 2008; 52:737–44.