Education in Home Dialysis: The Time Is Now

Most nephrologists consider peritoneal dialysis (PD) to be the best therapy for planned initiation of dialysis and frequent home-based hemodialysis (HD) as the best long-term therapy not only for patients with end stage kidney disease (ESKD) but also for themselves (1). A major barrier to increasing home dialysis therapies is the limited training in most US nephrology fellowship programs. Based on multiple national surveys, graduating trainees do not feel well trained and competent in either form of home dialysis (2, 3). Another survey of nephrology fellowship program directors identified lack of sufficient patients on PD for adequate exposure and faculty comfort as barriers to training (4, 5). This sets up a vicious cycle for underuse of these modalities, as today's graduating fellows are tomorrow's teachers and clinicians. Addressing physician comfort and closing knowledge gaps are tantamount to increasing patient modality choice.

Within a fellowship program, lack of exposure to patients using PD and faculty comfort can be addressed by developing relationships with local dialysis units with large home dialysis populations overseen by nephrologists experienced in the modality. Clinical exposure should be supplemented by didactics with curricula including home dialysis infrastructure, training, access management, available technologies, modality and solution selection, prescription writing, complication management, and reimbursement (6). Those desiring academic research careers in home dialysis can pursue a home dialysis fellowship, such as those offered by Mount Sinai, McMaster University, and the University of Toronto; however, clinical competency is a must for all fellows by the conclusion of their second year.

Several resources exist to supplement fellowship education. Conferences with extensive didactics on home dialysis include American Society of Nephrology (ASN) Kidney Week, the Annual Dialysis Conference, Nephrology Business Leadership University (NBLU), and the National Kidney Foundation (NKF) Spring Clinical Meeting. Courses such as the Home Dialysis University offer an immersive 2.5-day experience dedicated to all aspects of home dialysis. In addition, online coursework provided by the ASN Dialysis Advisory Group and an industry symposium endorsed by the North American Chapter of the International Society for Peritoneal Dialysis (ISPD) are freely available.

Beyond fellowship, education can also be imparted in the form of lecture series and webinars covering a broad range of topics. One such health educational model is Project ECHO (Extension for Community Healthcare Outcome) in which teleconferencing is used to enhance medical resources in communities that lack specialized care (7). An application in home dialysis was proposed in the landmark NKF-Kidney Disease Outcomes Quality Initiative (KDOQI) report (7). Through this program, clinical experts in home dialysis can provide online coaching for learners. Case studies are discussed to highlight various issues related to patients on home dialysis. Problem-solving techniques can be taught through interactive simulation programs. Virtual mentoring can be made available for troubleshooting actual cases.

Home dialysis education during nephrology fellowship training is quite inconsistent. We believe home dialysis training during fellowship should be similarly emphasized in the Accreditation Council for Graduate Medical Education (ACGME) common program requirements as is done for kidney transplantation where 2 months of service is mandated, and a minimum of 10 new kidney transplants are to be followed (8). Similar guidance should be provided for home dialysis therapies where it is currently lumped with the 4-month exposure to dialysis in general: “four months of experience with dialysis therapies, both hemodialysis and peritoneal dialysis” (8). Furthermore, the American Board of Internal Medicine (ABIM) should devote more attention to home dialysis modalities, where currently, it is not listed separately on the ABIM Nephrology certification examination blueprint but is presumably contained within several categories (9). Last, in order to sit for the ABIM Nephrology boards, only PD is listed as a procedure requirement and not home HD. The ABIM Nephrology board should similarly list home HD as a training and procedure requirement (10).

Programs should develop a standardized curriculum, identify gaps in training, and use the numerous educational resources to bridge these gaps in order to enhance the educational experience for the fellows. Attention should be focused not only on the management of patients who have chosen a home modality but also on the processes that support that choice, particularly predialysis education. The promotion of dedicated faculty members to undergo advanced training would add to growth of home dialysis programs within the institutions and allow a more meaningful educational experience through direct patient care.

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