Keeping Home Dialysis Patients at Home

Abstract

Related Article, p. 629 Related Article, p. 629 Home dialysis, whether peritoneal dialysis or hemodialysis (HD), has many purported benefits. Specifically, in observational studies, home HD (HHD) is associated with significant survival benefits, although dissecting true benefits from possible selection bias, such that healthier patients may be electing HHD, is always difficult. A recent Australian and New Zealand analysis, based on registry information but carefully controlled for biases, demonstrated significantly improved survival for long-hours HHD patients compared with conventionally treated center-based HD patients,1Marshall M.R. Polkinghorne K.R. Kerr P.G. Hawley C.M. Agar J.W.M. McDonald S.P. Intensive hemodialysis and mortality risk in Australian and New Zealand populations.Am J Kidney Dis. 2016; 67: 617-628Abstract Full Text Full Text PDF Scopus (38) Google Scholar and the FHN (Frequent Hemodialysis Network) trials demonstrated improved outcomes for (in-center) short-daily HD compared to conventional treatment.2The FHN Trial GroupIn-center hemodialysis six times per week versus three times per week.N Engl J Med. 2010; 363: 2287-2300Crossref PubMed Scopus (823) Google Scholar Although the home-based nocturnal HD arm of the trial failed to return a statistically significant outcome, this trial was markedly underpowered.3Rocco M.V. Daugirdas J.T. Greene T. et al.Long term effects of frequent nocturnal hemodialysis on mortality: the Frequent Hemodialysis Network (FHN) nocturnal trial.Am J Kidney Dis. 2015; 66: 459-468Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 4Rocco M.V. Lockridge R.S. Beck G.J. et al.The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network nocturnal trial.Kidney Int. 2011; 80: 1080-1091Abstract Full Text Full Text PDF PubMed Scopus (403) Google Scholar An important factor in determining HHD success is the patient’s engagement with his or her own care. HHD patients are responsible for their own dialysis sessions, needling, and fluid removal. If a problem occurs (eg, fluid overload), they are expected to troubleshoot it. Although support is available for this from dialysis nurses and physicians, the patient, perhaps with the assistance of a caregiver, is the first responder and needs to be prepared to handle any eventualities. This responsibility may be one reason why technique failure is not uncommon among patients treated with home therapies. In this issue of AJKD, Seshasai et al5Seshasai R.K. Mitra N. Chaknos C.M. et al.Factors associated with discontinuation of home hemodialysis.Am J Kidney Dis. 2016; 67: 629-637Abstract Full Text Full Text PDF Scopus (36) Google Scholar evaluate the rate of discontinuation in a cohort of US HHD patients treated by DaVita, a large national dialysis provider organization in the United States. Included in analyses were 2,840 patients receiving HHD between January 2007 and December 2009. In this cohort, 24.9% discontinued HHD therapy at 1 year (or 29.4/100 patient-years), not including the 7.6% who died and 7% who underwent transplantation in that time. As noted by the authors, this discontinuation rate was far higher than seen in other countries. For example, in Australia/New Zealand data derived from the ANZDATA (Australia and New Zealand Dialysis and Transplant Registry), 23% of patients reportedly discontinue at 2 years,6ANZDATA Report. Chapter 5: Haemodialysis. http://www.anzdata.org.au/anzdata/AnzdataReport/36thReport/2013c05_haemodialysis_v1.7.pdf. Accessed November 18, 2015.Google Scholar whereas a second recent Australian report, specifically targeting extended-hours dialysis in ANZDATA, noted technique failure rates of 10%, 23%, and 32% at 1, 3, and 5 years, respectively.7Jun M. Jardine M.J. Gray N. et al.Outcomes of extended-hours hemodialysis performed predominantly at home.Am J Kidney Dis. 2013; 61: 247-253Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar As reported by Seshasai et al5Seshasai R.K. Mitra N. Chaknos C.M. et al.Factors associated with discontinuation of home hemodialysis.Am J Kidney Dis. 2016; 67: 629-637Abstract Full Text Full Text PDF Scopus (36) Google Scholar in their discussion, rates of discontinuation in the United Kingdom and Canada vary from 3% to 15% at 1 year. There are 3 important considerations arising from this information. (1) Is there something different about HHD in the United States compared with other countries? (2) Can we identify the reasons behind this? (3) Can we do anything to help the problem? With regard to the first question, there are potentially several important differences between this US HHD cohort and those in other countries. Although most of the HHD patients studied by Seshasai et al5Seshasai R.K. Mitra N. Chaknos C.M. et al.Factors associated with discontinuation of home hemodialysis.Am J Kidney Dis. 2016; 67: 629-637Abstract Full Text Full Text PDF Scopus (36) Google Scholar were performing short-daily HD using NxStage equipment, most HHD elsewhere is conventional (thrice weekly for 4-5 hours per session) or long-hours HD (eg, at least alternate day for 7-8 hours per session) performed with standard dialysis machines. Certainly, as the authors point out, others have had similar experiences with technique failure with short-daily programs. For example, the initial study from Weinhandl et al8Weinhandl E.D. Nieman K.M. Gilbertson D.T. Collins A.J. Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients.Am J Kidney Dis. 2015; 65: 98-108Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar reported discontinuation rates of 21.3/100 patient-years in a cohort of 3,400 HHD patients using the NxStage system. Another notable apparent difference is shorter training time. Although not included in the Seshasai et al report, the DaVita website claims to train most HHD patients in 3 to 5 weeks,9Davita Inc. Home hemodialysis overview. http://www.davita.com/services/home-hemodialysis. Accessed November 18, 2015.Google Scholar a factor that likely affects patients’ subsequent responses to troubleshooting emergencies and cannulation problems. We believe that training in access cannulation and fistula care is as important as learning how to operate the dialysis machine, and this takes time and patience. In our experience, we usually use 6 to 8 weeks (or more) of training, in part to ensure comfort with access cannulation and managing minor mishaps. Potentially, funding for HHD training in the United States could be a significant factor in the duration of training and thus needs attention at a regulatory level. Seshasai et al point out the greater engagement in HHD in Australia, New Zealand, and other countries. They correctly highlight that this means that more doctors, nurses, and patients are cognizant of HHD and are keener to promote it.10Ludlow M. George C.R. Hawley C.M. et al.How Australian nephrologists view home dialysis: results of a national survey.Nephrology. 2011; 16: 446-452Crossref PubMed Scopus (61) Google Scholar They attempted to address the issue of unit size as a factor and could find no correlation of unit size with technique failure. However, we would argue that a mean HHD unit size of 3.9 ± 7.1 patients in the US study cannot test this adequately. In Australia and New Zealand, for example, many HHD programs exceed 50 patients. HHD in the United States is often assisted remotely by dialysis companies. This is a different business model from that of most other countries. Dialysis consumable supplies are delivered by a third party and machine maintenance is also provided by a third party. In the United Kingdom, Australia, and New Zealand, units are directly and actively engaged with HHD and the patient interacts with staff at many levels with a team familiar with each other.11Mitra S. Cress C. Goovaerts T. Workforce development and models of care in home hemodialysis.Hemodial Int. 2015; 19: S43-S51Crossref Scopus (8) Google Scholar This direct interaction with dialysis personnel who are well known to the patient may exceed that in the United States. Although it is difficult to definitively identify this as a reason for discontinuation, we believe it may be a significant issue. It is often stated that a reason for the high uptake of HHD in Australia and New Zealand is the remoteness of much of both countries. Although there are patients dialyzing in remote areas, Australia is surprisingly one of the more urbanized countries, with current World Bank figures listing 89% of people living in major urban areas, compared with 81% to 82% in the United Kingdom, Canada, and United States.12The World Bank. Urban population (% of total). http://data.worldbank.org/indicator/SP.URB.TOTL.IN.ZS. Accessed November 19, 2015.Google Scholar In the Seshasai et al report, rural residence showed a trend to association with remaining on dialysis therapy, with the reasonable assumption that the inconvenience of otherwise traveling for dialysis was a factor. Outside the United States, most patients enter directly into HHD programs at the start of their HD journey rather than after the 2 or more years’ dialysis vintage described in the DaVita cohort. Seshasai et al could not find an association of dialysis vintage with discontinuation. However, because very few patients seemingly started HHD at zero vintage, it may not be possible to test this adequately. The Australia/New Zealand view is that we need to distance HHD patients from any experience of the easy no-responsibility center-based dialysis environment to avoid them being drawn into this path without first considering the home option. We have expanded the “peritoneal dialysis first” approach of some countries13Li P.K. Chow K.M. Peritoneal dialysis-first policy made successful: perspectives and actions.Am J Kidney Dis. 2013; 62: 993-1005Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar to one of “home first.” There is a long list of possible reasons for discontinuation of HHD therapy, which were unable to be addressed in the Seshasai et al report due to lack of available data. Issues such as patient and caregiver burnout and cannulation problems are likely to be more common in HHD programs, particularly with frequent HD regimens.7Jun M. Jardine M.J. Gray N. et al.Outcomes of extended-hours hemodialysis performed predominantly at home.Am J Kidney Dis. 2013; 61: 247-253Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar The FHN trials highlighted potential access issues associated with daily programs.2The FHN Trial GroupIn-center hemodialysis six times per week versus three times per week.N Engl J Med. 2010; 363: 2287-2300Crossref PubMed Scopus (823) Google Scholar Duration of training, intensity of training, who provides the training, involvement of a caregiver, and potential overly heavy reliance on a caregiver rather than emphasizing self-reliance are all potential issues that could result in modality failure. Interestingly, solo nocturnal HHD is commonly practiced in Canada, Australia, and New Zealand,14Kerr P.G. Agar J.W.M. Hawley C.M. Alternate night nocturnal hemodialysis: the Australian experience.Semin Dial. 2011; 24: 664-667Crossref Scopus (12) Google Scholar whereas many US providers prohibit unaccompanied HHD. Understanding the patient and caregiver response to shouldering the burden of responsibility of HHD is likely also important.15Agar J.W.M. Home hemodialysis in Australia and New Zealand: practical problems and solutions.Hemodial Int. 2008; 12: S26-S32Crossref PubMed Scopus (22) Google Scholar What can be done to improve the situation? With significant personal biases, we believe that for the US circumstance, consideration needs to be given to longer training times, greater concentration on individual patient care, and increasing the role of the patient. Short-daily dialysis in the home environment is predominantly a US phenomenon. It is unclear whether a shift to longer-hours HD with less intensive regimens would help, but the limited experience with alternate-day nocturnal programs would suggest that discontinuation rates are lower with this approach.7Jun M. Jardine M.J. Gray N. et al.Outcomes of extended-hours hemodialysis performed predominantly at home.Am J Kidney Dis. 2013; 61: 247-253Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Having said that, all countries practicing HHD experience patient discontinuations, and we all need to pay particular attention to patient and caregiver burnout. Providing opportunities for respite dialysis and holiday dialysis options to allow patients and caregivers to regain their energy and enthusiasm is as important in dialysis as it is in the general population. Support: None. Financial Disclosure: Drs Kerr and Agar have been or are members of clinical advisory boards to Fresenius, Baxter, and Quanta Fluid Solutions. Peer Review: Evaluated by the Deputy Editor and the Editor-in-Chief. Factors Associated With Discontinuation of Home HemodialysisAmerican Journal of Kidney DiseasesVol. 67Issue 4PreviewHome hemodialysis (HHD) is associated with improved clinical and quality-of-life outcomes compared to in-center hemodialysis, but remains an underused modality in the United States. Discontinuation from HHD therapy may be an important contributor to the low use of this modality. This study aimed to describe the rate and timing of HHD therapy discontinuation, or technique failure, and identify contributing factors. Full-Text PDF