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 a 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 non-adherence 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. As a Patient Advocate for NxStage and a Patient Ambassador for DaVita, I am able to discuss home dialysis opportunities with patients before, during, and after their dialysis treatments, while they are in the waiting room or in the dialysis chair. In addition, I make it a point to visit facilities in my area and speak with the managing doctors, nurses and techs about how incredible dialyzing at home is. I am also rather unique in that I am a walking billboard that defeats almost every excuse for not offering a home dialysis option.
How, you ask? Well, first off I personally suffer from anemia and acute hypotension. The three-day a week, in-center model exacerbates these issues greatly. To work around the hypotension, I have to have more frequent dialysis treatments and at a slower pull-rate. That takes a chair away from another billable person because current insurance guidelines do not allow a facility to bill for more than three treatments a week and facilities only have so many chairs. Most facilities have a waiting list as well. Anyway, back to me.
According to the State of Georgia, I am considered "almost legally blind". My acute hypotenstion from in-center dialysis caused my optic nerves to be starved of oxygenated blood which caused me to lose 83% of my visual field. So, I am anemic, hypotensive and nearly blind. I am also the only person in my area certified in not only nocturnal home-hemodialysis but also solo home hemodialysis using NxStage's System One equipment. That's right. As blind as I am, I do not need a partner to perform dialysis in the comfort of my own home. I insert my own needles into my fistula, attach the machine and away I go. Four hours later, I go on with my day. If I want to do a nocturnal treatment, my Wife is there to make sure i do not sleep through any alarms. I now dialyze 5 days a week, nocturnally, for 7.5 hours a night and I feel better now then when I had two functioning kidneys.
You see, education regarding opportunities for dialysis at home is crucial. Patients who are more informed about home dialysis tend to choose home 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.
I suggest to facilities that they allow all patients who wish to attempt home dialysis, the opportunity to learn how to cannulate themselves while still in-center. When they can successfully insert and remove their own needles, they are committed to the process of home therapy and can then 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 my first clinic, I had to seek a seek a second opinion regarding home dialysis because I had been denied that option. They told me it was because my blood pressure was to low or their fluid levels were to high between treatments, so I must not be adhering to their prescribed treatment and medication schedules. They were right. I wasn't because it wasn't designed specifically for what my body needed. I have heard other doctors tell patients that 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. Medical Director's can look at it from a business perspective too. You have a center that CMS only allows you to treat x patients per shift and you run two shift per day, six days a week. Each patient is their three days a week. If you transition patients out of the facility ino home dialysis, you free up that chair for someone else. Now you are able to bill for the new person in the in-center chair and continue to bill for the patient now dialyzing at home. 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 you were the patient, would you expect any less than to have the opportunity to choose the type of care that best suits your needs.
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 Care2003; 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.