Episode 13: The Rise of Home Dialysis with Dr. Michael Kraus
With the ability to provide patients greater control over their own treatment and improve their quality of life, home dialysis is a core component of the care model at Fresenius Medical Care North America. Even the federal government is pushing to see more patients treated at home. Dr. Michael Kraus, Associate Chief Medical Officer of Fresenius Kidney Care, joins Field Notes to break down the benefits of home treatment and provide insight into the company’s strategy and approach.

Brad Puffer: Welcome, everyone to this episode of Field Notes. I'm Brad Puffer on the Medical Office Communications Team at Fresenius Medical Care, North America, and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

Home dialysis is a core component of our patient care model. We believe that every patient should be empowered to do their dialysis treatments at home, which can lead to a higher quality of life. We have had success with over a 15% rise in home treatments in just the past year. Even the federal government is pushing to see more patients treated at home, providing new incentives to make that happen.

While our care teams work to educate, support, and empower patients, nephrologists will also need more tools to better support this growing number of home dialysis patients. Here to dive into this important topic in kidney care is Dr. Michael Kraus, Associate Chief Medical Officer for Fresenius Kidney Care. We're thrilled to have Dr. Kraus with us today. A leading expert in home dialysis, Dr. Kraus is also a Professor Emeritus of Clinical Medicine at Indiana University School of Medicine. He has also been a practicing nephrologist for more than 20 years. Dr. Kraus, welcome to Field Notes.

Dr. Michael Kraus: Well, thanks for having me, Brad. I'm always happy to help with Field Notes and talk about home dialysis anytime.

Brad Puffer: Well, Dr. Kraus, I'd like to start off with a little bit about your background. You clearly have a passion for kidney care and, especially, home dialysis. What made you such a believer?

Dr. Michael Kraus: Well, when I was a renal Fellow back at the University of Iowa in the late '80s, I was fortunate enough to work with people who believed in home dialysis. And I learned quite a bit and that was certainly the start. And then there was the big change with the new devices. And I was able to see the changes in patients' lives-- were able to be empowered and take care of themselves, and deliver therapy that made them better, healthier, and happier.

Brad Puffer: Well, I've often heard you talk about this term "more frequent dialysis" which refers, in a lot of ways, to home dialysis. How does the frequency of home compare and what are the advantages?

Dr. Michael Kraus: That's an excellent question because we try to figure out what makes the home patient a better patient. Some of it may be that they're just taking care of themselves, right? Any empowered patient, that's better. But when you look at the closeness of it, the biggest problem our patients have is salt and water and the cardiac function. And when you look at how we dialyze people, in general, this thrice a week business that we usually do, it allows the heart to get more salt and water impact between dialysis sessions.

By increasing the frequency of dialysis, we're able to prevent this cardiac loading of salt and water. So what it does is it takes dialysis, that we provide quite well on a thrice weekly basis, but moving it more frequent means we can take the symptoms from dialysis away, we can load the heart and we can control salt water better.

Brad Puffer: From your experience and working with patients directly, who do you believe does best on home dialysis?

Dr. Michael Kraus: You know, Brad, that is a million question with multiple changes recently. And my point over the last, particularly last 17 years when I've been doing more of the more frequent dialysis in the home and watching patients do well, it really is almost any patient with end stage renal disease and the motivation to succeed. It really changes the question to, who does well on dialysis to who shouldn't be on home dialysis.

And that barrier, that hurdle, actually decreases quite a bit. And almost any home dialysis patient that wants to do it and is motivated and has enough support-- it could even be independent, you don't necessarily need a lot of support-- but in the household you live in, can do this. And the people that can't or I have the biggest concerns are those that have untreated mental illness or untreated alcohol or drug abuse. Because then it becomes a level of safety. Certainly, we have to do things. If you live alone and your blind, home hemodialysis would be very difficult, but peritoneal dialysis would not.

So it's a matter of looking at the patient, getting to understand how we can treat them and how we can make it easier for them to succeed at home. And so the bottom line is, almost all patients can do well but it's incumbent on the patient to have motivation to succeed and be adherent. And it's incumbent on us to have the engagement to figure out how best to teach the patient and help them through whatever barriers they have.

Brad Puffer: So does that mean you think to nephrologists really need to come at this with a home first mentality.

Dr. Michael Kraus: As I practiced, home first mentality is probably a reasonable thing. But I tend to change that. I mean this really should be a patient first mentality. What is best for my patient-- starting in CKD. Pre-emptive transplantation-- I know that's not the topic of today-- is essential for the quality of our patients' lives and improving the mortality in our patients as well.

But transplant and home dialysis is better for most of our patients. And the majority of our patients can do it safely. So, yes, home first mentality is good, but it's probably better a patient first mentality.

Brad Puffer: How and when do you first begin that conversation about home dialysis and treatment modality choice? I assume the earlier that we can educate patients on their options, the better. But that's not always possible, is it?

Dr. Michael Kraus: No, and there's a lot of barriers to even beginning that conversation. The easy thought processes, yes, you start early, you train the patients early, you give them all this education, and then everything will be good and everybody will do home dialysis. The reality is that's a part of how we train, but that's not really the answer. And when I took care of patients with chronic kidney disease, I would start early.

But early was very little education. I want to prevent you from going to dialysis and these are the things that we're going to do. We're going to control your blood pressure. We're going to change your diet. We're going to work on exercise and weight loss, and all the things that we work on to slow the progression of end stage renal disease to dialysis. But eventually you might need dialysis. And I'm going to teach you about it, but I'm not going to spend a lot of time on it. I'm going to teach you a little bit along the way.

And that's the perfect way to do that-- to slowly bring it in and increase the education throughout the course. Unfortunately, you've got to teach people when they want to hear and when they're physically and emotionally able to hear. So sometimes if you start that conversation too early, they shut it off because they don't even want to talk about dialysis and clearly you have that patient.

So you've got to judge from each patient. And one of the beautiful things, and I think Dr. Chatoth did a very nice job on transitional care Field Notes with you the other day, is the transitional care unit. Because when that patient does go to dialysis, that's when they are ready to learn. They have to learn. That's when you teach somebody about cancer is when they have the diagnosis. You don't talk about chemotherapy to someone who doesn't have cancer. When you have the SRD, It's in front of you.

So the beauty of the transitional care unit is we're teaching people when they want the information and when they can accept the information-- we clear the medical conditions in the early week of transitional care. We have the social worker work aggressively with them, particularly in the early process of transitional care, to get rid of the depression, anger, and anxiety. So that we can then teach them what they need to learn, when they need to do it.

But each patient is different. And remember even half of our patients, we don't get to early on. Half of patients-- what we term we use is crash into dialysis-- where they come to us requiring dialysis in less than six months, which takes away that ability to start early education.

Brad Puffer: Well, Dr. Kraus, you mentioned earlier about having that mentality that anybody can do home dialysis or at least starting with that idea. And so, as an example, do you have patients that even surprised you? People that you said, I wouldn't have expected this person to do well at home, but all of a sudden, they're doing well and thriving.

Dr. Michael Kraus: Yeah, I think we see that both with peritoneal dialysis and home hemodialysis. And you learn that when you're good at what you do with home dialysis, you're not selecting patients for home dialysis. They're selecting you to deliver that home dialysis.

One of my favorite patients was a lady I picked up while she was in-center dialysis. She was about 78 years old. She didn't speak English. And she had a really bad heart. She was in the hospital about every six weeks with a fluid overload situation. And she just wasn't doing well. She was now in a wheelchair. Her blood pressure was poorly controlled. And her cognitive function was declining. She wasn't eating.

And she was the kind of patient that we look at, in the in-center world, and say, this lady has a long-term survival of likely somewhere between two and six months. So we have the conversation with the patient and the family. And we talk about options of care. And when you go through the list in her, we were left with home hemodialysis-- for reasons we couldn't do peritoneal dialysis in her.

And in this case, her daughter, that would be doing the care, also ran the family restaurant. Who worked 60, 70 hours. So my nurses looked at the patient as too sick to go home and looked like a patient that would clearly fail at home. But we had the conversation. And at the end of the day, the family said, we want to do whatever it will take to try and make mom better.

So they agreed to more frequent dialysis at home. We put her on more frequent dialysis at home with a very good schedule-- 15 hours a week, about six days a week-- good clearances. And we brought down her dry weight a little bit. We got her off blood pressure pills completely. She threw away her wheelchair, was ambulatory-- walked. And lived a wonderful happy life-- depression went away-- for another nine years.

She had, in those nine years, rather than being in the hospital three or four times a year, she was in the hospital four times over nine years. None of them related to salt and water. None of them related to dialysis. So we gave her a huge quality of life-- a huge quantity of life that we didn't anticipate in a candidate that clearly, we all looked at, and said, boy, this is really going to be hard. And I don't think she's going to do well.

Brad Puffer: Yeah, that's an amazing story, Dr. Kraus, to just hear that and imagine that there must be so many others out there that have similar stories, or people that have not even been given the option of home dialysis but could be helped.

Dr. Michael Kraus: You've got to look at each patient and realize that everybody's different. And they live in different houses than you do. They may live in small houses where we have to figure out how to take care of storage of supplies and all the things. And we have to make sure-- the whole house doesn't have to be perfectly clean, but where you do your dialysis has to be really clean. So work with the patients how to do those things.

And understand the family dynamics. And a good home dialysis program engages all of those things and helps the patient stay on dialysis-- doesn't look for reasons to take them off home dialysis.

Brad Puffer: Dr. Kraus, when you look back at your career, what has really changed the most when it comes to home dialysis?

Dr. Michael Kraus: The obvious one that comes forefront to me is in the home hemo world with the advent of low volume dialysate in the early 2000s. In fact, I got involved in 2002 before it was even FDA cleared. And then working with the growth of that program-- using more frequent dialysis five or six days a week, using low volume dialysis. It was a device that made it easy for my patients to go home.

Prior to that, my home hemo patients were all on conventional dialysis machines, as we're all familiar with, but 2003 was a big change to me. But the biggest change was the evidence that we've been able to generate that supports what we hypothesized would happen with the patients and seeing the patients improve. And now we have the evidence that says, we know that we make the heart better. We know that LVH or thickened heart's reduced. We know the blood pressure goes down and you come off blood pressure pills. We know that sleep improves. We know that quality of life improves. And the list goes on.

And we have good, strong, firm evidence to support that. And now we've gone from a point where very few doctors use home hemodialysis to 2, 3, 4, 5 times more doctors are using it. 2, 3, 4, 5 times more patients are exposed to it. So we're seeing growth and acceptance. And that is probably the most change that I've seen, is the acceptance of home hemodialysis by physicians, nurses, and patients now.

Brad Puffer: Well, when you look at the official numbers from the United States Renal Data System, USRDS, it puts it at about 12.5% of patients using some type of home modality. Those are numbers from 2018, so they're a couple of years old. Do you feel that number is finally beginning to accelerate?

Dr. Michael Kraus: Oh, I think there's no question it is, Brad. Especially as we look within Fresenius Kidney Care, we're seeing rapid growth of both home hemodialysis and peritoneal dialysis. And it doesn't just happen. This has taken a lot of work over the last couple of years. A lot of vision by the leadership for Fresenius Kidney Care dating back to 2017, or so-- before my time here. Where they said, it's time for us to push home dialysis. How do we succeed in it? What are the resources we're going to need to be successful? And we've changed the culture of care within Fresenius Kidney Care.

So we've seen that already start to accelerate significantly. And I think the rest of the world is following along. Certainly with the ETC and the Executive Order regarding home dialysis, all of those are putting this in the right area to see us have more growth of home dialysis.

Brad Puffer: Are certain doctors still reluctant, despite all that effort, all that education, to prescribe home and why? Have nephrology fellowships really prepared doctors the right way to prescribe home therapies?

Dr. Michael Kraus: And the answer to that one is probably not. And actually Dr. Brent Miller and Nuper Gupta just put out a paper the other day showing that Fellows, that left their fellowship, when surveyed said, you know about 10% of them or just under, felt comfortable with home hemodialysis. And just under 50% felt comfortable with peritoneal dialysis. So these are people leaving their fellowship.

So the answer is, academics we haven't quite figured out how to get people prepared to prescribe home therapies. We have to. And the answer for physicians willing or reluctant to prescribe, is, first things, we have to get them comfortable. No question if I'm uncomfortable with a therapy, it's difficult for me to promote it and prescribe it.

So as Fresenius, obviously our job is to get those doctors there. We still have doctors that are a little bit uncomfortable with the therapy. It's our job to demonstrate to them that this is a safe and effective method, give them the evidence it takes to show the improvement in quality, and again, as we believe in Fresenius Kidney Care, that home dialysis is a preferred form of therapy for many of our patients. And make it so it's easy for them to do it. Make sure that they have the resources to get there.

Brad Puffer: And I know you've been part of an effort to create a Physician Home Champion program. Tell me about that program and how is that providing peer-to-peer mentorship and why is that so important?

Dr. Michael Kraus: The Physician Home Champion program is a program we've devised. The goal is to get people who are very good and true believers in home therapy. The goal of a physician home champion will be to educate, lead, and become the true leader of home therapies in their region. So the person the nurses look to. The person that our leadership looks to. The person that the other physicians in the area look to to help them grow home therapies.

So the beauty of it is it's working. I mean our physician home champions are getting involved. They're working with their Directors of Operations & their Senior Directors of home therapies. They're working with their nursing and with the other physicians in the area, even the ones that aren't in their groups. And they're troubleshooting the issues and the problems with home therapies in the area. And they're helping support the physicians within education-- empowering them.

So a physician home champion does everything. They're really a solid peer-to-peer mentor. They're well educated. They're empowered. We give them the resources they need. But more importantly, they're a valuable resource to the whole market.

Brad Puffer: Well, you've touched on just how committed Fresenius Kidney Care is to making home dialysis available to more patients. And I'm glad you brought up our recent Field Notes discussion with Dr. Dinesh Chatoth around transitional care units and their role in empowering more patients. How are excited are you for the future? What are a few of the biggest things on the horizon that you think will really help further accelerate this move to home?

Dr. Michael Kraus: I am truly stoked about the future. I mean frankly I changed my career as a successful academic nephrologist in administration to join industry because I saw the leadership that was at NxStage and knowing that it was going into Fresenius and understood the goals of the company to drive to home. And that meant that we are engaged. We're committed to providing resources and we'll get there.

So A, the last two years have seen tremendous growth in home dialysis. B, we're just scratching the surface. And the beauty is there is so much more we're going to accomplish in the next 1, 2, and 5 years that we're going to see just continued growth of home, and more importantly, improved quality of care in the home.

Because we will continue to bring the culture of home and bring the culture of good prescriptions. We'll drive home the importance of controlling volume in all modalities. I don't want just my home patients to do well, I want my in-center patients to do well. So we're going to continue to improve care. And it's just really an exciting place to be, frankly.

Brad Puffer: And when you look ahead to everything we're doing around connected health technologies-- telehealth, refining and improving our products, even new PD solution bags that were just announced to make it easier for patients-- it seems like it's the education, it's the doctors, it's the support, it's the products, the technology and it's all coming together. And it's really exciting.

Dr. Michael Kraus: The pipeline is big. And the engineers behind the scenes are really bright. And they're working every day to make this a better therapy, to make it less burdened for the patient at home, and improve the quality of care. And telehealth this is a beautiful example of what we've been able to do because we have the right people in the right places.

And we've been able to bring to the physician, and the patient, and the nurses, a product that works and that they use and they use thousands of times every day. So it is what we're doing today, it's where we want to be tomorrow, and it's the culture of the company-- from engineering, to education, to patient care, to quality, to ops, to everybody. It's just an exciting place to be.

Brad Puffer: Well, Dr. Kraus, it's been really great discussing this topic with you today. Thank you for joining us.

Dr. Michael Kraus: Thanks, Brad. It's been fun.

Brad Puffer: And to our audience, thank you for joining us. Don't forget, you can find Field Notes on the Apple Store or Google Play or right here at fmcna.com where you can also find our annual medical report and other featured articles. We hope you'll come back and join us as we have many more topics to discuss in the weeks ahead.

Until next time, I'm Brad Puffer. And you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.