The home dialysis first paradigm: suitability and transitioning

Abstract

Patients with progressive renal insufficiency are faced with a multitude of decisions and choices during the continuum of their care. Those that choose to embark on the road to renal replacement therapy are faced with complicated decisions regarding modality choice and possibly transplantation. Others may proceed with palliative pre-dialysis care, without considering any further therapy. Empowerment of patient choice or autonomy is now felt to be central to medical decision making [1]. It seems evident that in the past, many patients with end-stage renal disease (ESRD) have reported that they did not receive all the information required to make an informed choice about dialytic modalities [2]. Lameire and colleagues introduced an integrated care approach to modality decision making more than 10 years ago [3]. Their approach was to intimately plan pre-dialysis care with timely referral to a renal multidisciplinary team, timely preparation for dialysis followed by timely initiation. Peritoneal dialysis (PD) was their focus of the initial modality of choice for suitable patients with timely transfer to in-center hemodialysis (HD) as a rescue therapy should PD be inadequate. Although this approach was a welcome one in regard to attempting to integrate or streamline pre-dialysis care, it had a number of shortcomings. Mendelssohn and Pierratos identified four important deficiencies with this approach including a lack of emphasis on the following: (1) decreasing the rate of progression of chronic kidney disease, (2) management of cardiovascular risk and other comorbidities, (3) consideration of home HD, pre-emptive transplant, and PD as the initial modality for suitable patients, and (4) empowerment of patient choice [4]. Mendelssohn and Pierratos indicated a number of reasons why home HD is a good initial modality [4]. The advantages listed in their 2001 editorial still hold today (and some are more robust with the supporting data that has accrued since then). Briefly, home HD has the following advantages: (1) improved extracellular fluid volume and blood pressure control, (2) liberalization of the diet, (3) patient independence and flexibility, (4) improved quality of life, (5) reduced erythropoietin-stimulating agent utilization, (6) possible survival benefits, (7) possibly comparable lifeexpectancy results as transplantation, and (8) more cost-effective than in-center HD (after approximately M. Benaroia Division of Nephrology, Grand River Hospital, 835 King Street, West, Kitchener, ON N2G 1G3, Canada