Hemodialysis With the Quanta SC+: Efficacy and Safety of a Self-care Hemodialysis Machine

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.

Portable, wearable and implantable artificial kidney systems: needs, opportunities and challenges

Haemodialysis is life sustaining but expensive, provides limited removal of uraemic solutes, is associated with poor patient quality of life and has a large carbon footprint. Innovative dialysis technologies such as portable, wearable and implantable artificial kidney systems are being developed with the aim of addressing these issues and improving patient care. An important challenge for these technologies is the need for continuous regeneration of a small volume of dialysate. Dialysate recycling systems based on sorbents have great potential for such regeneration. Novel dialysis membranes composed of polymeric or inorganic materials are being developed to improve the removal of a broad range of uraemic toxins, with low levels of membrane fouling compared with currently available synthetic membranes. To achieve more complete therapy and provide important biological functions, these novel membranes could be combined with bioartificial kidneys, which consist of artificial membranes combined with kidney cells. Implementation of these systems will require robust cell sourcing; cell culture facilities annexed to dialysis centres; large-scale, low-cost production; and quality control measures. These challenges are not trivial, and global initiatives involving all relevant stakeholders, including academics, industrialists, medical professionals and patients with kidney disease, are required to achieve important technological breakthroughs.

Two Years' Experience of Intensive Home Hemodialysis with the Physidia S3 System: Results from the RECAP Study

The RECAP study reports results and outcomes (clinical performances, patient acceptance, cardiac outcomes, and technical survival) achieved with the S³ system used as an intensive home hemodialysis (HHD) platform over a three-year French multicenter study. Ninety-four dialysis patients issued from ten dialysis centers and treated more than 6 months (mean follow-up: 24 months) with S³ were included. A two-hour treatment time was maintained in 2/3 of patients to deliver 25 L of dialysis fluid, while 1/3 required up to 3 h to achieve 30 L. The additional convection volume produced by means of the SeCoHD tool (internal filtration backfiltration) was 3 L/session, and the net ultrafiltration produced to achieve dry weight was 1.4 L/session. On a weekly basis, an average 156 L of dialysate corresponding to 94 L of urea clearance when considering 85% dialysate saturation under low flow conditions was delivered. Such urea clearance was equivalent to 9.2 [8.0-13.0] mL/min weekly urea clearance and a standardized Kt/V of 2.5 [1.1-4.5]. The predialysis concentration of selected uremic markers remained remarkably stable over time. Fluid volume status and blood pressure were adequately controlled by means of a relatively low ultrafiltration rate (7.9 mL/h/kg). Technical survival on S³ was 72% and 58% at 1 and 2 years, respectively. The S³ system was easily handled and kept by patients at home, as indicated by technical survival. Patient perception was improved, while treatment burden was reduced. Cardiac features (assessed in a subset of patients) tended to improve over time. Intensive hemodialysis relying on the S³ system offers a very appealing option for home treatment with quite satisfactory results, as shown in the RECAP study throughout a two-year follow-up time, and offers the best bridging solution to kidney transplantation.

The coronavirus disease 2019 pandemic: the disruptor that maintenance dialysis never anticipated

PURPOSE OF REVIEW

The novel coronavirus 2019 (COVID-19) pandemic has upended maintenance dialysis in the United States. I review changes in prevalence, incidence, mortality, and other clinical outcomes among patients undergoing dialysis since March 2020, highlighting vulnerabilities in the current system and opportunities for improved care in the future.

RECENT FINDINGS

The number of dialysis patients in the United States declined between March 2020 and March 2021, an unprecedented year-over-year drop in the census. Some of the decline can be attributed to an early drop in patients initiating dialysis but most of the decline can be attributed to excess mortality. Kidney transplants also declined during the early part of the pandemic. Home dialysis utilization increased during 2020 but that increase was largely in line with secular trends. The rate of hospitalization for causes other than COVID-19 fell significantly during 2020.

SUMMARY

The epidemiology of dialysis in the United States is clearly modifiable, as it reflects decisions to initiate treatment, prescribe home therapies, and hospitalize patients with acute medical needs. On the other hand, some outcomes are powerfully guided by health outcomes in the general population, thus limiting the ability of dialysis providers and nephrologists to influence outcomes.

Cost-Effectiveness of Home Hemodialysis With Bedside Portable Dialysis Machine "DIMI" in the United Arab Emirates

Background and objective

The incidence and prevalence of patients requiring renal replacement therapies (RRTs) are increasing worldwide and a large number of these patients die prematurely due to the unavailability of treatment. While in-center hemodialysis remains the most commonly practiced modality globally, more and more patients find it unsuitable due to their frail condition, difficulty in ambulation, and time lost in traveling, etc. Such patients find the self-administered or nurse-assisted home hemodialysis (NAHHD) more suitable. The costly and recurring nature of these therapies prompted us to evaluate and compare the cost-effectiveness aspect of these two treatment modalities. Thus, the aim of the study was to investigate if home hemodialysis (HHD) with a portable hemodialysis machine was cost-effective in comparison to in-center hemodialysis for patients of end-stage renal failure (ESRF) in the United Arab Emirates (UAE). This is the first study of its kind to be conducted in the UAE.

Methodology

The study topic was developed based on an informal inquiry from the health regulator of Abu Dhabi if HHD was cost-effective compared to in-center hemodialysis with an emphasis on a portable dialysis machine. No such head-to-head study performed in the UAE was available. Hence, a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) design was chosen as the investigative method. An outline of the study was drafted, and a literature search of Science of Web, PubMed, and Cochrane Evidence was performed using the keywords "Home Hemodialysis", "home-based Dialysis", "Cost-effectiveness of Dialysis", "Cost-effectiveness of renal replacement therapy", etc. A review of the article titles was performed to include the articles relevant to the cost of RRTs and the economic burden of ESRF. Full text and abstracts of those articles were retrieved, studied, and, the articles that were found not relevant were excluded. The remaining articles were studied and used in the evidence synthesis. DIMI was chosen to represent a standard type of recently developed portable dialysis machines.

Results

It was interesting to find out during the review that HHD and in-center hemodialysis had been developed simultaneously but the former had eventually fallen out of favor. The review revealed that HHD is not only as effective as in-center hemodialysis but is also associated with better survival benefits over the latter. Several studies have found it to be significantly cost-effective compared to in-center hemodialysis. Newer types of HHD machines make it easier for the patients or their family/caregivers to administer it safely and effectively at home and while traveling. They have regenerated interest in HHD and the Medicare administration in the USA has already decided to make use of it at a more frequent rate.

Conclusion

Based on the evidence in the available literature, HHD is cost-effective when compared to in-center hemodialysis in terms of survival benefits, quality of life (QoL) of patients, and monetary savings. Newer portable bedside dialysis machines provide better safety and have simplified the procedure of hemodialysis, making HHD more acceptable to patients and caregivers. We believe HHD should be the preferred modality of treatment instead of in-center hemodialysis, and that applies to UAE too.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.