Choosing Home Hemodialysis: A Critical Review of Patient Outcomes

BACKGROUND/AIM

Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL).

METHODS

Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL.

RESULTS

Regarding mortality, 10 of 13 trials reported 13-52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body mass index in HHD vs. ICHD patients, while others found no significant differences. There were no significant differences in the rate of hospitalization between HHD and ICHD in the 6 articles reviewed. Seven studies on QoL demonstrated positive trends in HHD vs. ICHD populations.

CONCLUSIONS

Despite limitations in the current data, 66% of the publications reviewed (29/44) demonstrated improved clinical outcomes in patients who chose HHD. These include improved survival, CV, nutritional, and QoL parameters. Even though HHD may not be preferred in all patients, a review of the literature suggests that HHD should be provided as a modality choice for substantially more than the current 1.8% of HHD patients in the United States.

[Home Daily Hemodialysis with NxStage System One: monocentric italian casistic results]

NxStage System One is a new dialytic technology based on easy setup, simplicity of use and reduced dimensions, which is increasingly in use worldwide for home hemodialysis treatments. The system utilizes a low amount of dialysate, usually 15-30 liters according to anthropometric patients' values. The dialysate is supplied at very low flux, generally about 1/3 of blood flow, in order to obtain an elevated saturation of dialysate for solutes. In these conditions the clearance of urea will be almost equal to dialysate flow rate. In order to achieve an obptimal weekly clearance evaluated by Std Kt/V the dialysis sessions are repeated six times a week. In this way a good control of blood voleme can be reached. In this paper we report our experience of treatment with NxStage System One in 12 patients from May 2011 to Dicember 2016.

Nursing home care. Daily HHD vs conventional dialysis: A survival comparison

Patients that dialyze in the nursing home setting are known to be an especially at-risk vulnerable population compared to the overall ESRD population. This is likely due to the nursing home dialysis patients' advanced age, multiple co-morbidities, and frailty, requiring skilled nursing support. These challenges often result in worse outcomes compared to the overall end-stage renal disease (ESRD) population but few studies have investigated interventions to improve health outcomes in this population. Previously, we reported results from a study using a large epidemiological database of patients from an independent nursing home dialysis provider, showing that patients treated with daily home hemodialysis had improved outcomes compared to patients treated with conventional dialysis. One limitation of the previous study was that the timeframe for the two comparison groups was different; therefore, the results could have been due to over-all improvements in care over time unrelated to the modality of dialysis: To address this as well as expand on the previous analysis, the objective of the present study was to compare outcomes in ESRD patients in the nursing home setting treated with daily home hemodialysis versus con- ventional three-day-a-week (TIW) hemodialysis using an updated database, specifically assessing patients treated during a concurrent time: frame. Health status was evaluated for 6,314 patients (n=4,778 conventional, n=1,902 daily home hemodialysis; 2006 to November 2015 for conventional; 2011 to November 2015 for daily home hemodialysis). Analyses included monthly mortality rates, Kaplan-Meier survival analysis, and laboratory values. In the "Compared to the conventional dialysis population, daily HHD patients had similar or lower incident mortality rates." analysis of patients treated during the concurrent timeframe, median overall survival was 36 months with daily home hemodialysis versus 21 months with conventional dialysis (P=0.0025). These results were similar to the analysis of all patients regardless of timeframe. Compared to the conventional dialysis population, daily home hemodialysis patients had similar or lower incident mortality rates. Survival rates were higher at 3 months (89% vs 82%), 6 months (84% vs 73%), and 12 months (74% vs 62%) in the daily home hemodialy- sis population compared to conventional dialysis population. Monthly mean albumin was consistent over time in the daily home hemodialysis population but gradually increased in the conventional dialysis population. Hemoglobin values were consistently lower over the follow-up period in the daily home hemodialysis population and ferritin values were similar in both populations. These results confirm and extend previous findings that daily home hemodialysis is associated with improved patient outcomes compared to conventional hemodialysis. Although difficult to conduct practically, a prospective randomized outcomes study evaluating daily home hemodialysis versus conventional TIW dialysis would be valuable in informing the standard of dialysis care in this population.

The economic considerations of patients and caregivers in choice of dialysis modality

Introduction Broader adoption of home dialysis could lead to considerable cost savings for health services. Globally, however, uptake remains low. The aim of this study was to describe patient and caregiver perspectives of the economic considerations that influence dialysis modality choice, and elicit policy-relevant recommendations. Methods Semistructured interviews with predialysis or dialysis patients and their caregivers, at three hospitals in New Zealand. Interview transcripts were analyzed thematically. Findings 43 patients and 9 caregivers (total n = 52) participated. The three themes related to economic considerations were: (i) productivity losses associated with changes in employment; (ii) the need for personal subsidization of home dialysis expenses; and (iii) the role of socio-economic disadvantage as a barrier to home dialysis. Patients weighed the flexibility of home dialysis which allowed them to remain employed, against time required for training and out-of-pocket costs. Patients saw the lack of reimbursement of home dialysis costs as unjust and suggested that reimbursement would incentivize home dialysis uptake. Social disadvantage was a barrier to home dialysis as patients' housing was often unsuitable; they could not afford the additional treatment costs. Home hemodialysis was considered to have the highest out-of-pocket costs and was sometimes avoided for this reason. Discussion Our data suggests that economic considerations underpin the choices patients make about dialysis treatments, however these are rarely reported. To promote home dialysis, strategies to improve employment retention and housing, and to minimize out-of-pocket costs, need to be addressed directly by healthcare providers and payers.

Intensive Home Hemodialysis Results in Regression of Left Ventricular Hypertrophy and Better Clinical Outcomes

BACKGROUND

Left ventricular hypertrophy (LVH) is an independent risk factor for mortality and cardiovascular events in patients with end-stage renal disease. Studies have shown that frequent hemodialysis leads to LVH regression, but the impact of left ventricular mass (LVM) regression on clinical outcomes remains unknown.

METHODS

This observational cohort study assessed the impact of LVH regression on the composite outcome of time to all-cause mortality, technique failure or cardiovascular hospitalization in patients on home hemodialysis. LVH regression was defined as either a reduction of more than 10% in LVM in patients with LVH at baseline or prevention of LVH in those without LVH at baseline. Risk factors associated with progression of LVM were also examined.

RESULTS

We studied 144 intensive hemodialysis patients between 1999 and 2012 with a mean follow-up of 4.7 years. Eighty-seven patients (60.4%) had LVH regression or prevention and 57 patients (39.6%) had LVH progression. In a multivariate analysis, smoking (OR 2.78, 95% CI 1.06-7.36) and presence of LVH at baseline (OR 2.21, 95% CI 1.06-4.59) were significant predictors for LVM progression. Sixteen patients (18.4%) in the regressor group and 19 patients (33.3%) in the progressor group developed the composite end point. When adjusted for age and diabetes, regression was significantly associated with a decreased risk (hazards ratio (HR) 0.42, 95% CI 0.21-0.84) for the composite end point. Regression was also significantly associated with a decreased risk of death in the adjusted analysis (HR 0.20, 95% CI 0.06-0.67).

CONCLUSIONS

Regression of LVH with intensive hemodialysis is associated with favorable clinical outcomes.

Outcomes among patients receiving in-center, self-care hemodialysis

Modalities of renal replacement therapy are categorized into incenter hemodialysis and home therapies. A subset of hemodialysis patients referred to as in-center self-care hemodialysis (ICSCHD) receive patient training as if they were going home but instead perform their dialysis in-center with minimal staff support. Preliminary data suggests ICSCHD is associated with better outcomes than traditional in-center hemodialysis. We looked at ICSCHD patients initiating maintenance dialysis from April 1, 2011 to March 30, 2014 and compared them at a 1:2 ratio to propensity-score matched controls from surrounding facilities within the same catchment area. The median follow-up was 14 months. Patients on ICSCHD had lower mortality rate (0.02 vs 0.07 per patient year; p <0.05), fewer hospitalization events (0.82 vs. 1.70 per patient year; p = 0.008) and fewer missed treatments (1.1% vs 3.8% of all treatments; p = 0.005) than matched controls. We concluded that patients on ICSCHD had lower mortality rates and fewer hospital days than well-matched controls and spent more time on dialysis and missed fewer treatments. Establishing a facility-wide.

CQI proiect Every other day nocturnal HHD - An alternative approach to reduce burden

More frequent dialysis, typically performed five to six times per week at home, has been associated with a num- ber of clinical, cardiovascular, and health-related quality of life (HRQOL) benefits. Daily therapy often results in a burden for patients and care partners. A continuous qual- ity improvement (CQI) initiative was conducted to evaluate if an alternate day, longer duration therapy (3.5 treatments with six to 10 hour treatments per week) would provide a viable alternative for home hemodialysis (HHD). This initia- tive demonstrated that every other day (EOD) nocturnal HD is a feasible alternative option to daily HHD and should be considered to individualize home dialysis therapy.

Effects of physician payment reform on provision of home dialysis

OBJECTIVES

Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment.

STUDY DESIGN

Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform.

METHODS

We conducted difference-in-difference analyses comparing patients with traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities.

RESULTS

Patients with traditional Medicare coverage experienced a 0.7% (95% CI, 0.2%-1.1%; P = .003) reduction in the absolute probability of home dialysis use following payment reform compared with patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI, 0.5%-1.4%; P < .001) reduction in home dialysis use following payment reform compared with patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians).

CONCLUSIONS

The transition from a capitated to a tiered fee-for-service payment model for in-center hemodialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts.

Improving kidney care for residents in nursing facilities: a national model

The RRC Staff Assisted Home Hemodialysis Program started in September 2013 with the target of improving care for the frail elderly residents in skilled facilities by offering hemodialysis in their home setting. Residents all receive short time, frequent dialysis. The residents no longer need to be transported to a local dialysis center three times per week in all types of weather and subject to long waits by the transport company. In addition, Medicare/Medicaid save significant dollars on transportation expenses. Residents needing rehabilitation services can receive their therapy while their dialysis schedule is adjusted around the resident's therapy. Residents no longer miss meals and medications or family visits. Collaboration between RRC and the skilled facility is patient centric whereby the care of each patient is consistent and individualized. The most meaningful measure of the success of this program is the residents themselves. They have self-reported how much better they feel with more energy. The residents can increase their socialization activities within the skilled facility. The dietitians report that the residents are eating better because there are fewer restrictions on foods and fluids.

Understanding safety-critical interactions with a home medical device through Distributed Cognition

As healthcare shifts from the hospital to the home, it is becoming increasingly important to understand how patients interact with home medical devices, to inform the safe and patient-friendly design of these devices. Distributed Cognition (DCog) has been a useful theoretical framework for understanding situated interactions in the healthcare domain. However, it has not previously been applied to study interactions with home medical devices. In this study, DCog was applied to understand renal patients' interactions with Home Hemodialysis Technology (HHT), as an example of a home medical device. Data was gathered through ethnographic observations and interviews with 19 renal patients and interviews with seven professionals. Data was analyzed through the principles summarized in the Distributed Cognition for Teamwork methodology. In this paper we focus on the analysis of system activities, information flows, social structures, physical layouts, and artefacts. By explicitly considering different ways in which cognitive processes are distributed, the DCog approach helped to understand patients' interaction strategies, and pointed to design opportunities that could improve patients' experiences of using HHT. The findings highlight the need to design HHT taking into consideration likely scenarios of use in the home and of the broader home context. A setting such as home hemodialysis has the characteristics of a complex and safety-critical socio-technical system, and a DCog approach effectively helps to understand how safety is achieved or compromised in such a system.

Survey of home hemodialysis patients and nursing staff regarding vascular access use and care

Vascular access infections are of concern to hemodialysis patients and nurses. Best demonstrated practices (BDPs) have not been developed for home hemodialysis (HHD) access use, but there have been generally accepted practices (GAPs) endorsed by dialysis professionals. We developed a survey to gather information about training provided and actual practices of HHD patients using the NxStage System One HHD machine. We used GAP to assess training used by nurses to teach HHD access care and then assess actual practice (adherence) by HHD patients. We also assessed training and adherence where GAPs do not exist. We received a 43% response rate from patients and 76% response from nurses representing 19 randomly selected HHD training centers. We found that nurses were not uniformly instructing HHD patients according to GAP, patients were not performing access cannulation according to GAP, nor were they adherent to their training procedures. Identification of signs and symptoms of infection was commonly trained appropriately, but we observed a reluctance to report some signs and symptoms of infection by patients. Of particular concern, when aggregating all steps surveyed, not a single nurse or patient reported training or performing all steps in accordance with GAP. We also identified practices for which there are no GAPs that require further study and may or may not impact outcomes such as infection. Further research is needed to develop strategies to implement and expand GAP, measure outcomes, and ultimately develop BDP for HHD to improve infectious complications.

Modalities and prescribing strategies in intensive home hemodialysis: a narrative review

Over the past decades, evidence on the benefits of intensive hemodialysis, more frequent and longer comparing to conventional hemodialysis, has emerged. The home environment is an ideal setting to perform intensive hemodialysis without the reliance on organizational and structural needs. The observed benefits of frequent hemodialysis have resulted in a rise in prevalent intensive home hemodialysis patients around the world. A successful home hemodialysis program requires a well-structured predialysis education program with focus on home dialysis and a dedicated multidisciplinary team with knowledge about the specifics of home hemodialysis and with a holistic approach to provide optimal care. In this narrative review, we describe different modalities of home hemodialysis and dialysis prescription specifics of intensive nocturnal hemodialysis, the modality with overall best outcomes.

[Assisted peritoneal dialysis]

According to the National Registry of Renal Replacement Therapy (RRT), the incidence of chronic kidney disease (end-stage renal disease) and the need of RRT have declined in the last decade renal. One of the reasons for this tendency certainly is transplantation as the best choice. However, transplant procedure has limitations in elderly patients due to the number of comorbidities. This study was designed as retrospective analysis of outcomes in patients treated with peritoneal dialysis for a period of eleven years. Patients were divided into those who had been assisted or unassisted. Out of 100 patients treated with peritoneal dialysis (PD), 77 completed the treatment, including 26 assisted and 51 unassisted patients. Peritonitis was recorded in 20 assisted and 26 unassisted patients. Peritonitis was more common in unassisted patients, who were more frequently lost from PD. Assisted PD could be a good and safe choice of RRT in this special group of patients.

Risk of vascular access complications with frequent hemodialysis

Frequent hemodialysis requires using the vascular access more often than with conventional hemodialysis, but whether this increases the risk for access-related complications is unknown. In two separate trials, we randomly assigned 245 patients to receive in-center daily hemodialysis (6 days per week) or conventional hemodialysis (3 days per week) and 87 patients to receive home nocturnal hemodialysis (6 nights per week) or conventional hemodialysis, for 12 months. The primary vascular access outcome was time to first access event (repair, loss, or access-related hospitalization). Secondary outcomes were time to all repairs and time to all losses. In the Daily Trial, 77 (31%) of 245 patients had a primary outcome event: 33 repairs and 15 losses in the daily group and 17 repairs, 11 losses, and 1 hospitalization in the conventional group. Overall, the risk for a first access event was 76% higher with daily hemodialysis than with conventional hemodialysis (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.11-2.79; P=0.017); among the 198 patients with an arteriovenous (AV) access at randomization, the risk was 90% higher with daily hemodialysis (HR, 1.90; 95% CI, 1.11-3.25; P=0.02). Daily hemodialysis patients had significantly more total AV access repairs than conventional hemodialysis patients (P=0.011), with 55% of all repairs involving thrombectomy or surgical revision. Losses of AV access did not differ between groups (P=0.58). We observed similar trends in the Nocturnal Trial, although the results were not statistically significant. In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.

ENHANCING LIFESTYLE THROUGH HOME HAEMODIALYSIS

The Sydney Dialysis Centre (SDC) supports 150 patients who dialyze in the home environment. Since its inception SDC has been assisting patients to modify their dialysis regime according to individual needs. In 2003-2004 a postal survey was sent to SDC patients who had changed their dialysis regime to ascertain the effect of this change on lifestyle. This article will present the results of the survey with regard to patients who dialyze nocturnally (LND) and for longer hours (LH). The patients experience will be presented in relation to their reason for modifying treatment, resultant changes in diet and medication prescription and their subjective experience of wellbeing. Findings indicate that patients who dialyse nocturnally and for longer hours experience improved sense of wellbeing, diet control and increased energy levels. While nocturnal dialysis does not suit all patients, the respondents in this survey reported benefits such as: increased opportunity for employment; less restrictions on free time; improved blood results and better lifestyle.