Benefits of Home Hemodialysis

Benefits of Home Hemodialysis

For many reasons including trends to improve patient engagement in treatment and delivery of cost-efficient care, there is growing interest and effort in increasing use of home dialysis therapies. Peritoneal dialysis has been the leading home dialysis modality, but new technology is making it easier for patients to consider home hemodialysis (HHD). HHD is an underutilized modality today with the 2018 United States Renal Data Systems (USRDS) reporting that HHD was used by only 3.1 percent of all new patients starting dialysis in 2016.1 HHD utilization has grown steadily in the past two decades with 18 percent of all home therapy dialysis patients using HHD in 2016 compared to only 6.7 percent of home therapy patients in 2000.1

Home therapies in general offer improved patient outcomes and engagement. Studies show that HHD particularly with more frequent dialysis (MFD) is associated with improved clinical outcomes including improvement in:2-5

• BP control with fewer antihypertension medications
• Volume management
• Left ventricular hypertrophy (LVH)
• Phosphate control
• Fewer hospital days and hospitalizations

Well controlled studies accounting for patient selection bias also suggest improved survival for HHD patients compared to in-center HD patients.4

HHD has significant benefits as a patient-centered dialysis treatment.  By definition HHD patients assume a lot of responsibility for treatment parameters and delivering the prescribed treatment. Home training includes developing patient and care partner skills for pre-dialysis clinical assessment, treatment adjustment, and reporting especially regarding volume status for appropriate fluid removal. Patients and partners often develop advanced skills in vascular access assessment and cannulation. 

Studies examining patient-centered HHD outcomes report significant improvement in a variety of symptoms including:4, 5

• Restless leg syndrome symptoms
• Post-dialysis recovery period
• Increased energy
• Sleep
• Nausea
• Cramping
• Reported quality of life (QOL)

Home therapy, HHD in particular, is a flexible therapy for patients providing freedom to adjust treatment time to meet work and leisure schedules. New HHD machines such as NxStage are designed to make it easy for HHD patients to perform treatments and travel. 

Dialyzing at home decreases the cost and stress of transportation to and from a dialysis facility.  For many patients this also decreases the time they will spend devoted to dialysis by eliminating time spent for post-dialysis recovery and travel to treatment centers. 

Key features of HHD and especially MFD and slow nocturnal HD are superior dialysis clearance and lower ultrafiltration rates. Better fluid removal and clearances allow people to have a more liberal diet and often decreased need for phosphorus-lowering medications. 

For women of childbearing age, nocturnal HHD and daily HHD improve the opportunity for conception and a greater likelihood of term birth compared to in-center HD.5-9

HHD is generally offered in three distinct treatment patterns:

• Conventional HD at home three times per week for about four hours per treatment
• Daily HHD with five to seven treatments per week for about two hours each
• Nocturnal HHD with long, slow overnight treatments of six to eight hours, each occurring every other night or up to six times per week

Conventional HHD offers the benefits of home therapy with regard to patient power and flexibility. Limiting treatment to three times per week may reduce patient and caregiver treatment burden but may incur some of the limitations for fluid control and dietary freedom that in-center HD patients experience.

Dosing of MFD either daily or nocturnal should be decided with three simple steps:

• Determine frequency based on desired benefits (five or more days to control volume loading, decrease LVH, control BP, and improve dialysis related symptoms/QOL)
• Determine weekly hours of treatment based on desired ultrafiltration rate (12-18 hours per week for daily or more than 30 hours per week for nocturnal)
• Determine volume of dialysate for small molecule control

While some are concerned with burden of increased days per weeks, therapy may actually be preferred due to improved outcomes and overall quality.

Daily or more frequent hemodialysis (MFH) provides good clearance and volume control improving cardiovascular outcomes. Daily treatment may increase vascular access complications with more frequent arteriovenous fistula (AVF) or arteriovenous graft (AVG) cannulation. 

Slow nocturnal HHD is well tolerated due to low blood flow rates and slow treatments that decrease the incidence of adverse symptoms during a dialysis treatment. Long treatment times at least three days per week and up to six days per week may be burdensome for some patients. Nocturnal HHD patients benefit from excellent clearances and improvements in ESRD symptoms and quality of life.

For all home therapy patients and caregivers, the burden of daily home treatments can lead to burnout and transition away from home therapies. Home therapy programs strive to provide options for respite care with in-home or in-center support. Other supportive programs including peer-to-peer mentoring may reduce patient and caregiver burden.5

With known clinical and patient benefits to HHD, why is it an underutilized therapy? Patients and families who receive CKD education and treatment options information are more likely to choose a home therapy including HHD. USRDS reports that only about 35 percent of new dialysis patients have received nephrology CKD care and fewer have received pre-dialysis treatment options information.1, 3 In addition, studies show that only about 15 percent of nephrologists feel comfortable with prescribing HHD and caring for patients on this therapy.3 Lack of a comprehensive late stage CKD program with strong patient education and support along with nephrologist lack of confidence in prescribing HHD are significant barriers to increasing HHD utilization.3

There is also a lack of Medicare reimbursement incentive for HHD for providers and facilities. Although it is notable that Medicare coverage for new dialysis patients who are Medicare eligible due to ESRD begins on day 1 of treatment for home therapy patients including HHD and begins on month 4 for patients who start in-center HD. 

Increasing HHD utilization results in improved patient outcomes, engagement, and overall quality of life. CKD education and nephrologist champions for HHD improve the likelihood that patients will start dialysis with HHD or transfer from in-center HD to HHD. New technologies that decrease the burden of HHD training and maintenance for patients and caregivers have also made it easier for patients to choose HHD, which offers better flexibility to accommodate travel and work schedules. 

References

1. United States Renal Data System. 2018 USRDS annual data report:  Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2018.
2. Home Hemodialysis. 2015  [cited 2019 March 28]; Available from: https://www.kidney.org/atoz/content/homehemo.
3. Hajj, J.J. and K. Laudanski, Home Hemodialysis (HHD) Treatment as Effective yet Underutilized Treatment Modality in the United States. Healthcare (Basel), 2017. 5(4).
4. Miller, B.W., et al., Choosing Home Hemodialysis: A Critical Review of Patient Outcomes. Blood Purif, 2018. 45(1-3): p. 224-229.
5. Perl, J., et al., Temporal Trends and Factors Associated with Home Hemodialysis Technique Survival in Canada. Clin J Am Soc Nephrol, 2017.
6. Chan, C. Clinical Advantages of Home Hemodialysis.  [cited 2019 March 27]; Available from: https://www.kidneynews.org/kidney-news/special-sections/home-dialysis/clinical-advantages-of-home-hemodialysis.
7. Leduc, V., et al., Pregnancy on short-daily home hemodialysis using low dialysate flow rate: A new hope for the end-stage renal disease patients. Hemodial Int, 2018. 22(2): p. 161-167.
8. Piccoli, G.B., et al., Pregnancy in dialysis patients in the new millennium: a systematic review and meta-regression analysis correlating dialysis schedules and pregnancy outcomes. Nephrol Dial Transplant, 2016. 31(11): p. 1915-1934.
9. Nadeau-Fredette, A.C., et al., End-stage renal disease and pregnancy. Adv Chronic Kidney Dis, 2013. 20(3): p. 246-52.