Home Home Hemodialysis Research Articles

Home Dialysis in Patients with Cardiovascular Diseases.

Kidney failure with replacement therapy and cardiovascular disease are frequently comorbid. In patients with kidney failure with replacement therapy, cardiovascular disease is a major contributor to morbidity and mortality. Conventional thrice-weekly in-center dialysis confers risk factors for cardiovascular disease, including acute hemodynamic fluctuations and rapid shifts in volume and solute concentration. Home hemodialysis and peritoneal dialysis (PD) may offer benefits in attenuation of cardiovascular disease risk factors primarily through improved volume and BP control, reduction (or slowing progression) of left ventricular mass, decreased myocardial stunning, and improved bone and mineral metabolism. Importantly, although trial data are available for several of these risk factors for home hemodialysis, evidence for PD is limited. Among patients with prevalent cardiovascular disease, home hemodialysis and PD may also have potential benefits. PD may offer particular advantages in heart failure given it removes volume directly from the splanchnic circulation, thus offering an efficient method of relieving intravascular congestion. PD also avoids the risk of blood stream infections in patients with cardiac devices or venous wires. We recognize that both home hemodialysis and PD are also associated with potential risks, and these are described in more detail. We conclude with a discussion of barriers to home dialysis and the critical importance of interdisciplinary care models as one component of advancing health equity with respect to home dialysis.

Patient Training and Patient Safety in Home Hemodialysis.

The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.

From Home to Wearable Hemodialysis: Barriers, Progress, and Opportunities.

Although the past two decades have seen substantial proportional growth of home hemodialysis in the United States, the absolute number of patients treated with home hemodialysis remains small. Currently available stationary hemodialysis devices for use in the home have inherent limitations that represent barriers for more widespread adoption by a larger proportion of individuals with kidney failure. These limitations include device weight and bulk, ergonomics considerations, technical complexity, vascular access challenges, and limited remote patient monitoring. Recent years have witnessed a resurgence in research and development of prototype wearable kidney replacement devices incorporating innovations in miniaturization, new biomaterials, and new methods for toxin clearance and dialysate regeneration. Recent work has built on five decades of incremental innovation in wearable dialysis concepts and prototypes, starting from the work by Kolff in the 1970s. Wearable dialysis devices that successfully overcome key persistent barriers to successful development and adoption of these technologies will radically reshape the landscape of kidney replacement therapies and have the potential to dramatically improve the lives of individuals living with kidney failure.

Enhancing Patient Autonomy in Home Hemodialysis: Innovations in 3D Printed Aids for Independent Tubing Connection

Home Hemodialysis(HD) is an advantageous alternative to in-center treatments, offering greater convenience, flexibility, and improved quality of life [1]. The rising prevalence of end-stage renal disease (ESRD) globally has increased the demand for accessible renal replacement therapies [2]. Factors such as an aging population, higher rates of chronic conditions, improved survival rates for chronic kidney disease patients, and increased healthcare access contribute to the growing burden on healthcare systems [3]. Home HD has gained prominence by enabling patients to receive treatment at home, providing control over their healthcare management [1]. It offers flexibility in scheduling, reduces travel time and costs, and creates a relaxed environment that positively impacts the patient experience [4]. Improved clinical outcomes, including better blood pressure control and enhanced quality of life, have been associated with home HD. However, challenges persist during the inlet/ outlet preparation and tubing connection phase, involving awkward elbow and wrist maneuvers, which can cause joint stress and discomfort [5]. Limited mobility or dexterity can further complicate the task, leading to potential complications. Addressing these challenges and promoting patient autonomy in tubing connection are crucial for improved treatment experiences and outcomes. Innovative solutions are being developed to facilitate independent tubing connection in home HD, empowering patients and reducing complications. Evaluations of the aids have shown promising results, enhancing patient outcomes and satisfaction [6].

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Nephrologists' Perspectives of the Potential Utilization of Home Hemodialysis in Saudi Arabia.

Home hemodialysis (HD) is an attractive renal replacement modality that has been shown to provide several benefits to the patient and health-care system. However, home HD programs have not been well-established in Saudi Arabia. We aimed to explore the perspectives of adult nephrology consultants in Saudi Arabia about the potential utilization of home HD via a survey-based cross-sectional study. The survey was distributed via email to all adult nephrology consultants practicing in Saudi Arabia and registered in the Saudi Society of Nephrology and Transplantation. Out of 236 invited consultants, 151 (64%) participated in the study. Half of the participants defined home HD as a trained patient who can independently perform his/her HD sessions at home. Eighty-one (54%) consultants have never managed a patient on home HD during their nephrology training period. More than 70% of participants believed that home HD provides advantages over in-center HD, and that its utilization in Saudi Arabia would be feasible. Although 40% of participants worked in centers with no accredited nephrology training program, most of the remaining participants believed that the local training program did not provide enough teaching about home HD to trainees. Patients' refusal, the nephrologists' lack of motivation and experience, a lack of administrative support, and the lack of infrastructure and nursing support were identified by most participants as the major barriers to the utilization of home HD in Saudi Arabia. Addressing these barriers would be the first step to facilitate initiatives aiming to establish home HD programs in this country.

Similar survival on home haemodialysis and automated peritoneal dialysis: an inception cohort study.

ABSTRACTBackgroundSeveral studies have shown superior survival of patients on home haemodialysis (HD) compared with peritoneal dialysis (PD), but patients on automated PD (APD) and continuous ambulatory PD (CAPD) have not been considered separately. As APD allows larger fluid volumes and may be more efficient than CAPD, we primarily compared patient survival between APD and home HD.MethodsAll adult patients who started kidney replacement therapy (KRT) between 2004 and 2017 in the district of Helsinki-Uusimaa in Finland and who were on one of the home dialysis modalities at 90 days from starting KRT were included. We used intention-to-treat analysis. Survival of home HD, APD and CAPD patients was studied using Kaplan–Meier curves and Cox regression with adjustment for propensity scores that were based on extensive data on possible confounding factors.ResultsThe probability of surviving 5 years was 90% for home HD, 88% for APD and 56% for CAPD patients. After adjustment for propensity scores, the hazard ratio of death was 1.1 [95% confidence interval (CI) 0.52–2.4] for APD and 1.6 (95% CI 0.74–3.6) for CAPD compared with home HD. Censoring at the time of kidney transplantation (KTx) or at transfer to in-centre HD did not change the results. Characteristics of home HD and APD patients at the start of dialysis were similar, whereas patients on CAPD had higher median age and more comorbidities and received KTx less frequently.ConclusionsHome HD and APD patients had comparable characteristics and their survival appeared similar.

Costs of Assisted Home Dialysis: A Single-Payer Canadian Model From Manitoba

Rationale & ObjectiveThe prevalence of kidney failure is increasing globally. Most of these patients will require life-sustaining dialysis at a substantial cost to the health care system. Assisted peritoneal dialysis (PD) and assisted home hemodialysis (HD) are potential alternatives to in-center HD and have demonstrated equivalent outcomes with respect to mortality and morbidity. We aim to describe the costs associated with assisted continuous cycling PD (CCPD) and assisted home HD.Study DesignCost minimization model.Setting & PopulationAdult incident maintenance dialysis patients in Manitoba, Canada.InterventionFull- and partial-assist home HD and CCPD. Full-assist modalities were defined as nurse-assisted dialysis setup and takedown performed by a health care aide, whereas partial-assist modalities only included nurse-assisted setup. Additionally, full-assist home HD was evaluated under a complete care scenario with the inclusion of a health care aide remaining with the patient throughout the duration of treatment.OutcomesAnnual per-patient maintenance and training costs related to assisted and self-care home HD and CCPD, presented in 2019 Canadian dollars.Model, Perspective, & Time FrameThis model took the perspective of the Canadian public health payer using a 1-year time frame.ResultsAnnual total per-patient maintenance (and training) costs by modality were the following: full-assist CCPD, $75.717 (initial training costs, $301); partial-assist CCPD, $67,765 ($4,385); full-assist home HD, $47,862 ($301); partial-assist home HD, $44,650 ($14,813); and full-assist home HD (complete care), $64,659 ($301).LimitationsThis model did not account for costs taken from the societal perspective or costs related to PD failure and modality switching. Additionally, this analysis reflects only costs experienced by a single center.ConclusionsAssisted home-based dialysis modalities are viable treatment options for patients from a cost perspective. Future studies to consider graduation rates to full self-care from assisted dialysis and the cost implications of respite care are needed.

Economic Impact of Home Hemodialysis

Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.

The Role of Incremental Peritoneal Dialysis in the Era of the Advancing American Kidney Health Initiative.

On July 10, 2019, President Trump signed the Advancing American Kidney Health (AAKH) Executive Order—an order that aims to shift care delivery for kidney failure to patient-centered home therapies ([1][1]). One main goal of AAKH is for 80% of patients with incident kidney failure to receive a

P1137FACTORS DETERMINING CHOICE OF DIALYSISI MODALITY AMONG PATIENTS INITIATING DIALYSIS. RESULTS OF THE PERIDIALYSIS STUDY

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein >50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea >30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

P1448FACTORS ASSOCIATED WITH INCREASED MORTALITY AFTER DIALYSIS INITIATION. RESULTS OF THE PERIDIALYSIS STUDY

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein >50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea >30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

SUN-187 MORTALITY RISK BY DIALYSIS MODALITY OVER 1997 TO 2017 IN THE AUSTRALIAN AND NEW ZEALAND DIALYSIS POPULATION

The relationship between mortality risk and modality can vary by era. We recently showed that improvements in mortality risk on home hemodialysis (HD) and peritoneal dialysis (PD) are outpacing those on facility HD in Australia and New Zealand (Am J Kidney Dis. 2015 Sep;66(3):489-98). Here, we extend those analyses by directly comparing mortality risk on home HD and PD relative to facility HD across different eras of the recent past. We studied all adult patients commencing renal replacement therapy in Australia and New Zealand in the 20 years prior 31-December-2017 using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). We compared mortality risk by modality across different eras of dialysis inception using Cox proportional hazards regression, adjusting for time-varying co-morbidity, demographics, presence and type of diabetes mellitus, late referral, primary renal disease, eGFR at dialysis inception, and initial treating center as a shared frailty. For the main analysis, we used an as-treated framework with time-varying modality and a 90-day lag for the attribution of death to modality. We performed a sensitivity analysis using an intention-to-treat framework with modality assigned at 90 days post-dialysis inception and no lag for the attribution of death. Given the non-proportional hazards for mortality between PD and HD, we repeated the analyses using eras of different lengths (4 x 5-year intervals, 3 x 7-year ones, 2 x 10-year ones). We censored patients at the end of each era to ensure the same maximum duration of follow-up within each era. The study cohort contained a maximum of 52,103 subjects with 19,667 deaths over 140,183 patient-years. 61% were males, median (IQR) age was 62 (22), 46.6% had diabetes mellitus. Compared to facility HD, home HD was associated with better survival by 30-50% across all eras. Compared to facility HD, all forms of PD were associated with poorer survival in earlier eras, but with similar or better survival in cohorts initiating dialysis more recently (e.g. for 2013-2017: continuous ambulatory PD hazard ratio 0.87, 95% confidence intervals 0.78-0.99; automated PD HR 0.90, 95% confidence intervals 0.82-1.00). The sensitivity analysis using the intention-to-treat framework did not meaningfully change estimates. Our study indicates that, despite increased comorbidity, survival outcomes on dialysis are improving with time. Most recently, home HD is associated with better survival relative to facility HD, and PD with similar or better survival. Our analyses have potential for residual confounding from the limited collection of co-morbidity, and lack of socioeconomic, medication and biochemical data in analyses. The results of our study may be due to improved pre-dialysis care, patient selection (eg dialysis modality selection and dialysis versus conservative care in the elderly), improvements in general care of patient co-morbidities and advances in dialysis technology and practice.

Home Dialysis Is Associated with Lower Costs and Better Survival than Other Modalities: A Population-Based Study in Ontario, Canada.

Background:How and where to initiate dialysis are policy challenges with enormous economic and health consequences. Initiating with home hemodialysis (HD) or peritoneal dialysis (PD) may reduce costs and improve outcomes but evidence is conflicting.Methods:We conducted a population-based study in patients aged ≥ 18 years who initiated chronic dialysis in the province of Ontario, Canada from 2006 to 2014 (N = 12,691) using linked administrative data. Patients were grouped by initial modality: facility HD, facility short daily or slow nocturnal (SD/SN) HD, PD, home HD. We estimated publicly-paid healthcare costs (2015 Canadian dollars; 1 = 0.947 US dollar) and survival, from dialysis initiation to March 2015.Results:By 5 years after dialysis initiation, mean 30-day costs (as-treated) for patients receiving PD and home HD were 50% and 64% lower, respectively, than for facility HD patients ($11,011). Approximately 50% of costs were unrelated to dialysis, reflecting high comorbidity in these patients. With covariate adjustment, mean 5-year cumulative costs were similar for initiators of home HD and PD ($304,178 and $349,338) and higher for facility HD initiators ($410,981). The highest 5-year unadjusted survival was for home HD patients (80%), followed by PD (52%), SD/SN HD (50%), and facility HD (42%).Conclusions:This study in a large cohort over 9 years provides new population-based evidence suggesting that initiating dialysis at home is cost-effective, with lower costs and better survival, than starting with facility HD. Survival differences persisted after adjustment for baseline characteristics but we could not adjust for functional status or severity of comorbidities.

Advancing American Kidney Health: Perspective from Fresenius Medical Care.

CKD is a unique character on the stage of noncommunicable diseases in the United States: high prevalence (>20% in adults), significant expense to public payers ($114 billion among Medicare fee-for-service enrollees), and relatively little investment in research ($29 per patient in National

SAT-043 HOME & SATELLITE HAEMODIALYSIS PATIENTS: A COMPARISON OF OUTCOMES

Home haemodialysis (HD) has been associated with improvements in clinical and non-clinical outcomes. Previous studies have shown improvements in biochemical parameters, intradialytic blood pressure control, reduction in recovery time after dialysis, reduction in frequency of adverse events including hospitalisation, and improved quality of life and survival. At the end of 2017, there were 1023 patients on home HD in Australia, accounting for 9.6% of HD patients. In comparison, satellite dialysis accounts for 51.4% of HD patients. Satellite HD requires patients to travel to the HD centre typically thrice weekly for 4-5 hours of dialysis per session. Home HD removes the need for travel while increasing dialysis hours to 5-8 hours on alternate days with less interference with other activities of living, as the majority of patients dialyse overnight. The aim of this study was to determine whether or not there were significant differences in outcomes between home and satellite HD patients in an Australian centre. Prevalent home HD patients from a tertiary centre were included as of January 2008, and incident patients were added up until June 2017. Three controls (satellite HD patients) were matched to each home HD patient on age, gender and cause of end stage kidney failure (ESKD) treated at our centre. The primary outcomes were all-cause mortality (censored for transplantation) and transplantation. Secondary outcomes were average biochemical levels (haemoglobin, corrected calcium, phosphate and parathyroid hormone), proportion of patients in each group with a haemoglobin below 100g/L and phosphate above 1.8mmol/L, and whether or not transplanted patients were alive 6 months post-transplant. 542 patients were included in the analysis with 2135 person-years of data. The incidence rate of death was 6 per 100 person-years. There were no significant between group differences in average age, gender, race, smoking status, late referral, or cause of ESKD. BMI was significantly higher in home dialysis patients – 30.2kg/m2 compared to 27.3kg/m2 (p<0.0001). There was significantly higher prevalence of cerebrovascular disease at baseline in satellite compared to home HD patients (p=0.001), but no differences in prevalence of lung disease, coronary artery disease, peripheral vascular disease, cancer, diabetes, or hepatitis C. Home dialysis patients had a significantly reduced risk of death (HR=0.28, 95% CI 0.17-0.47, p<0.001). Transplant rates were higher in home patients compared to satellite patients - 61.8% and 51.6% (p=0.03). Survival rate at 6 months post transplantation was very high in both groups – 99.5% in satellite dialysis patients and 100% in home dialysis patients. Proportion of patients with low Hb (defined as Hb < 100g/L) was not significantly different between groups (p=0.35). Proportion of patients with high phosphate (defined as phosphate > 1.80mmol/L) in satellite patients compared to home patients were 46.6% and 35.8% (p<0.05). Home HD is associated with reduced risk of mortality, increased rates of transplantation, and improved phosphate control in an Australian dialysis population. With only 9.6% of dialysis patients in Australia dialysing at home, it would be worthwhile working to improve access to home HD for Australians with ESKD.

Cost Controversies of a "Home Dialysis First" Policy.

Purpose of review:Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a “Home Dialysis First” policy with a primary focus on single-payer systems in a developed nation such as Canada.Sources of information:Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis.Methods:We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a “Home Dialysis First” policy.Key findings:First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a “Home Dialysis First” policy.Limitations:Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies.Implications:Implementation of a “Home Dialysis First” policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a “Home Dialysis First” policy.

Technique Failure in a Multicenter Canadian Home Hemodialysis Cohort

Increasing uptake of home hemodialysis (HD) has led to interest in characteristics that predict discontinuation of home HD therapy for reasons other than death or transplantation. Recent reports of practice pattern variability led to the hypothesis that there are patient- and center-specific factors that influence these discontinuations. Retrospective cohort study. Incident home HD patients at 7 centers in Canada between 2000 and2010. Treatment center, case-mix, and process-of-care variables. Technique failure (defined as discontinuation of home HD therapy for any reason other than training failure, death, or transplantation) and mortality. Regression modeling of technique failure using Cox proportional hazard models adjusting for treatment center and modifiable and nonmodifiable patient-level variables, censored for death and transplantation. The cohort consisted of 579 patients. Mean age was 49.9±14.1 years, 74% were of European ancestry, median dialysis vintage was 1.9 (IQR, 0.6-5.2) years, and 68% used an arteriovenous access. Mean duration of dialysis was 31.2±12.6 hours per week. Unadjusted 1- and 2-year technique survival and overall survival were 90% and 83% and 94% and 87%, respectively. Treating center was a strong predictor of technique failure and mortality, with HRs ranging from 0.37 to 5.11 for technique failure (1 of 6 centers with P<0.05 relative to the reference) and 0.17 to 8.73 for mortality (3 of 6 centers with P<0.05 relative to the reference). With baseline adjustment for center, only older age and more than 3 treatments per week remained significant predictors of technique failure, while no individual-level variables remained as significant predictors of survival. Limited statistical power. Home HD treating centers may influence technique failure and patient mortality independent of case-mix. The relationship between processes of care and patient outcomes requires further investigation.

Prospective monitoring of after-hours nursing and technologist support calls to a regional Canadian home hemodialysis program.

Increasing renal care providers offer home hemodialysis (HD) as a modality choice. There is considerable variation in the provision of after-hours on-call support for self-dialyzing patients and no literature describing the utility of this service. In this prospective, observational study we sought to monitor and classify the number and nature of interactions between home patients and our on-call nurses and technologists, and enumerate the number of adverse events averted by the availability of on-call staff. Our home HD unit provided 24-hour on-call patient support and during a 4-month period in 2012, we prospectively monitored all patient calls to this service. The nature of the calls was logged as nursing-related vs. technical. Call outcomes were classified according to whether patients were able to initiate/resume their treatments or whether additional interventions were required. During this period, our program cared for 58 home HD patients. Nurses fielded 172 calls and dealt with 239 issues. One hundred nine (46%) were clinical issues including 5 (2%) of a serious nature involving potential harm; 67 (28%) related to machine setup or alarms, 36 (15%) required a technologist to resolve, and 27 (11%) were deemed non-urgent. One hundred six issues were directed to technologists in 99 calls. Issues pertained to machine malfunction (45 calls-43%), machine set-up and alarms (25 calls-24%), or the water system (24 calls-23%). Only 12 calls (11.3%) were not of a technical nature. Nursing and technologist support allowed patients to initiate or continue their treatment 75% and 71% of the time, respectively. Home HD on-call services provide patients support to successfully continue their dialysis treatments by troubleshooting clinical and technical aspects of dialysis and by averting potential adverse events.

Dalteparin anticoagulation in paediatric home haemodialysis.

The aim of this study was to investigate whether dalteparin is a safe and effective anticoagulant for paediatric home haemodialysis (HD) and to assess the determinants of dosing. Data were collected for all children (< 18years) undergoing home HD from 2011 to 2017 at one large paediatric nephrology centre in the UK. All children had anticoagulation with dalteparin sodium according to a standardised protocol. Dalteparin safety was assessed by monitoring for accumulation, adequate clearance of dalteparin and adverse events. Dalteparin efficacy was assessed through monitoring for clot formation in dialysis circuits. Potential determinants of dalteparin dosing were assessed. Eighteen children were included, their median age at start was 12years, and 50% were male. Eighty-three percent of children had four home HD sessions each week, with a median total dialysis hours of 20h/week. Thirty-three percent of children had nocturnal home HD. Median dalteparin dose at 12-month follow-up was 40IU/kg (range 8-142IU/kg). Factors associated with higher dalteparin dosing requirements included a younger age of the child (p < 0.01), a lower blood flow rate (p < 0.01) and the use of a central venous line for dialysis access (p = 0.038). No children had evidence of bioaccumulation of dalteparin or inadequate clearance. No significant bleeding or adverse events were reported. Dalteparin is a safe and effective anticoagulant when used for paediatric home HD. In this study, there was no evidence of bioaccumulation or significant adverse events. Further research is required to directly compare dalteparin with unfractionated heparin (UFH) and evaluate anticoagulant choice for paediatric home HD.