Attitudes of nephrologists towards assisted home dialysis in Germany

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

A retrospective clinical and economic analysis of an assisted automated peritoneal dialysis programme in Western Australia

BACKGROUND

Assisted peritoneal dialysis (aPD) represents an alternative kidney replacement therapy for dialysis-dependent patients whose only other options are prolonged hospitalisations or transfer to in-centre haemodialysis (HD). Most programmes have not examined the role of temporary aPD, and there is limited data surrounding the economic implications of temporary aPD programmes. The main aim of this study was to describe the cost-effectiveness of an assisted automated peritoneal dialysis (aAPD) programme, for patients whose only reason to stay in hospital was the temporary inability to independently perform PD at home.

METHODS

Retrospective, single-centre analysis of 45 referrals for aAPD from November 2015 to May 2021. Two groups of patients were enrolled in the study: respite patients already established on PD (to facilitate discharge or prevent admission) and new patients who were not yet trained (to facilitate discharge). To calculate the cost differential, patients were allocated to either staying in hospital or transferring to centre-based HD with comparison to costs on aAPD. Costs were calculated using a healthcare system perspective over the duration of aAPD assistance. Clinical outcomes including peritonitis rate, hospitalisation and mortality were also assessed.

RESULTS

Overall, 1349 episodes of aAPD care were delivered. One thousand forty-two episodes (77%) were for respite patients and 307 episodes (23%) were for new patients awaiting training. The mean duration of assistance was 18 days for pretraining patients and 37 days for respite patients. Overall, the mean length of stay on the programme was 30 days with a range of 1-263 days (SD 43) and 73% of patients graduated to self-care PD. The cost of the aAPD programme was $242 per visit, with an average cost $7260 per patient-episode. The aAPD programme was significantly cheaper than the alternatives, with average hospitalization costs $46,170 per episode, and in-centre HD costs of $9667. $1.497 million was saved over the course of the study. Eleven hospitalisations occurred and the peritonitis rate was 0.8 episodes per patient-year. Two patients died while on aAPD.

CONCLUSION

This study provides the first detailed description of an aAPD respite programme in Australia. We conclude that the implementation of a temporary aAPD programme could lead to a significant reduction in healthcare costs, however peritonitis rates were high.

Assisted peritoneal dialysis in Europe: a strategy to increase and maintain home dialysis

Peritoneal dialysis (PD) is a form of kidney replacement therapy with the major advantage that it can be performed at home. This has a positive impact on patients' autonomy and quality of life. However, the dialysis population is ageing and physical and/or cognitive impairments are common. These limitations often form a barrier to PD and contribute to the low incidence and prevalence of PD in Europe. Assisted PD can be a solution to this problem. Assisted PD refers to a patient being assisted by a person or device in performing all or part of their dialysis-related tasks, thereby making PD more accessible to elderly but also younger frail patients. In this way, offering an assisted PD program can help lower the threshold for initiating PD. In this review, we provide an overview of the epidemiology of assisted PD in Europe, we discuss the different categories and clinical outcomes of assisted PD, and we present how assisted PD can be implemented in clinical practice as a possible strategy to increase and maintain home dialysis in Europe.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

INTRODUCTION

Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.

METHODS

Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.

RESULTS

Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.

CONCLUSION AND CALL TO ACTION

Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.

Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability

BACKGROUND

In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients.

METHODS

An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ ² tests and (ordinal) logistic regression.

RESULTS

In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07-10.68), non-academic centres (OR: 2.01; 95% CI: 1.09-3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35-6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was <10% (72% and 63%), while 27% of Scandinavian respondents reported a proportion of >30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21-3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76-4.47) of patients on home dialysis.

CONCLUSIONS

Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported.

[Prevalence, Costs of Medical Treatment and Modalities of Dialysis-dependent Chronic Renal Failure in Germany: Comparison of Dialysis Care of Nursing Home Residents and in Outpatient Units]

STUDY OBJECTIVES

Current estimates on the prevalence of chronic renal failure and the costs of dialysis in Germany's population are not available. The aim of this study was to assess the prevalence of dialysis-dependent chronic renal failure and treatment costs of dialysis-dependent patients in Germany as well as differences between those residing in nursing homes and those treated in outpatient units.

METHODS

Health insurance claims from 4.5 million anonymized patients in the WIG2 research database were analyzed. Patients of all ages who had received outpatient dialysis treatment for chronic renal failure in 2017 (using uniform value scale code 13602) were included. These insurance claims were extrapolated to the German statutory health insurance population and, using official statistics, further to the entire population of Germany. Data on comorbidities, use of health resources, and costs were compared among patients residing in nursing homes and those treated in outpatient units.

RESULTS

In 2017, there were 87,255 dialysis-dependent statutory health insurance patients (≙1,054 person/1 million population, pmp), and 100,202 in Germany's whole population (≙1,210 pmp). About 8% of dialysis-dependent patients (n=7,676) were living in nursing homes. Our analyses predict an increase in dialysis-dependent patients of about 20-23% (up to 120,000-123,000), with an increase of dialysis-dependent nursing home residents of 37-44% (up to 10,500-11,000) by 2040. Almost all dialysis-dependent patients were treated with hemodialysis; peritoneal dialysis was rarely observed. The average annual treatment costs for dialysis-dependent patients residing in nursing homes amounted to 57,205 Euro and 53,996 Euro per patient respectively, with total annual statutory health insurance treatment costs amounting to about 4.73 billion Euro in 2017.

CONCLUSION

This study presents current estimates for dialysis-dependent chronic renal failure in Germany. Our findings on prevalence are comparable to data from other European countries and suggest a considerable increase in dialysis dependency by 2040, particularly for nursing home residents, resulting in a further increase in dialysis care costs. Hemodialysis was the most commonly used dialysis modality in patients living both in and out of nursing care facilities, with peritoneal dialysis rarely being used.

Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study

BACKGROUND

Chronic kidney disease (CKD) is increasing in patients older than 65 years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life.

HYPOTHESIS

PD should be offered to patients over 65 years. We search for any unfavorable results that may advice not to recommend PD therapy for this group.

OBJECTIVE

To describe PD treatment and outcomes in patients > 65 years, to compare their results with patients < 65 years and to identify areas with room for improvement in a real-life study.

STUDY

Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018.

RESULTS

We included 2,435 PD patients, 31.9% were older than 65 years; there was a difference of 25 years between both groups. Median follow up was 2.1 years. Older than 65 years group had more comorbidity: Diabetes (29.5% vs 17.2%; p < 0.001), previous CV events 34.5% vs 14.0%; p < 0.001), Charlson index (3.8 vs 3.0; p < 0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65 years group (0.65 vs 0.45 episodes/patient/year; p < 0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65 years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1 years). The main cause of PD withdrawal was transplant in group < 65 years (48.3%) and transfer to HD in group > 65 years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). Multivariate Cox regression analysis showed a relation (HR [95%CI]) between mortality and age > 65 years 2.4 [1.9-3.0]; DM 1.6 [1.3-2.1]; CV events 2.1 [1.7-2.7]. Multivariate Cox regression analysis identify a relation between technique failure and age > 65 years 1.5 [1.3-1.9]; DM 1.6 [1.3-1.9] and previous transplant 1.5 [1.2-2.0].

CONCLUSION

Patients older than 65 years fulfilled PD adequacy criteria during the follow up. We believe PD is a valid option for patients older 65 years. It is necessary to try to prevent infections and patient/caregiver fatigue, to avoid HD transfer for reasons not related to technique failure.

Expanding Utilization of Home Dialysis: An Action Agenda From the First International Home Dialysis Roundtable

In a groundbreaking meeting, leading global kidney disease organizations came together in the fall of 2020 as an International Home Dialysis Roundtable (IHDR) to address strategies to increase access to and uptake of home dialysis, both peritoneal dialysis and home hemodialysis. This challenge has become urgent in the wake of the coronavirus disease 2019 (COVID-19) pandemic, during which patients with advanced kidney disease, who are more susceptible to viral infections and severe complications, must be able to safely physically distance at home. To boost access to home dialysis on a global scale, IHDR members committed to collaborate, through the COVID-19 public health emergency and beyond, to promote uptake of home dialysis on a broad scale. Their commitments included increasing the reach and influence of key stakeholders with policy makers, building a cooperative of advocates and champions for home dialysis, working together to increase patient engagement and empowerment, and sharing intelligence about policy, education, and other programs so that such efforts can be operationalized globally. In the spirit of international cooperation, IHDR members agreed to document, amplify, and replicate established efforts shown to improve access to home dialysis and support new policies that facilitate access through procedures, innovation, and reimbursement.

Challenges and Opportunities in Expanding Home Hemodialysis for 2025

The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.

Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study

BACKGROUND

Chronic kidney disease (CKD) is increasing in patients older than 65years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life.

HYPOTHESIS

PD should be offered to patients over 65years. We search for any unfavorable results that may advice not to recommend PD therapy for this group.

OBJECTIVE

To describe PD treatment and outcomes in patients >65years, to compare their results with patients <65years and to identify areas with room for improvement in a real-life study.

STUDY

Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018.

RESULTS

We included 2,435 PD patients, 31.9% were older than 65years; there was a difference of 25years between both groups. Median follow up was 2.1years. Older than 65years group had more comorbidity: Diabetes (29.5% vs 17.2%; p<0.001), previous CV events 34.5% vs 14.0%; p<0.001), Charlson index (3.8 vs 3.0; p<0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65years group (0.65 vs 0.45 episodes/patient/year; p<0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1years). The main cause of PD withdrawal was transplant in group <65years (48.3%) and transfer to HD in group >65years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). Multivariate Cox regression analysis showed a relation (HR [95%CI]) between mortality and age>65years 2.4 [1.9-3.0]; DM 1.6 [1.3-2.1]; CV events 2.1 [1.7-2.7]. Multivariate Cox regression analysis identify a relation between technique failure and age>65years 1.5 [1.3-1.9]; DM 1.6 [1.3-1.9] and previous transplant 1.5 [1.2-2.0].

CONCLUSION

Patients older than 65years fulfilled PD adequacy criteria during the follow up. We believe PD is a valid option for patients older 65years. It is necessary to try to prevent infections and patient/caregiver fatigue, to avoid HD transfer for reasons not related to technique failure.

A Systematic Review and Jurisdictional Scan of the Evidence Characterizing and Evaluating Assisted Peritoneal Dialysis Models

BACKGROUND AND OBJECTIVES

Compared with hemodialysis, home peritoneal dialysis alleviates the burden of travel, facilitates independence, and is less costly. Physical, cognitive, or psychosocial factors may preclude peritoneal dialysis in otherwise eligible patients. Assisted peritoneal dialysis, where trained personnel assist with home peritoneal dialysis, may be an option, but the optimal model is unknown. The objective of this work is to characterize existing assisted peritoneal dialysis models and synthesize clinical outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, Embase, PsycINFO, and CINAHL was conducted (search dates: January 1995-September 2018). A focused gray literature search was also completed, limited to developed nations. Included studies focused on home-based assisted peritoneal dialysis; studies with the assist provided exclusively by unpaid family caregivers were excluded. All outcomes were narratively synthesized; quantitative outcomes were graphically depicted.

RESULTS

We included 34 studies, totaling 46,597 patients, with assisted peritoneal dialysis programs identified in 20 jurisdictions. Two categories emerged for models of assisted peritoneal dialysis on the basis of type of assistance: health care and non-health care professional assistance. Reported outcomes were heterogeneous, ranging from patient-level outcomes of survival, to resource use and transfer to hemodialysis; however, the comparative effect of assisted peritoneal dialysis was unclear. In two qualitative studies examining the patient experience, the maintenance of independence was identified as an important theme.

CONCLUSIONS

Reported outcomes and quality were heterogeneous, and relative efficacy of assisted peritoneal dialysis could not be determined from included studies. Although the patient voice was under-represented, suggestions to improve assisted peritoneal dialysis included using a person-centered model of care, ensuring continuity of nurses providing the peritoneal dialysis assist, and measures to support patient independence. Although attractive elements of assisted peritoneal dialysis are identified, further evidence is needed to connect assisted peritoneal dialysis outcomes with programmatic features and their associated funding models.

Integrated care: enhancing transition from renal replacement therapy options to home haemodialysis

Transition is an intrinsic process in the life of a patient with kidney disease and should be planned and anticipated when possible. A single therapy option might not be adequate across a patient’s entire lifespan and many patients will require a switch in their treatment modality to adapt the treatment to their clinical and psychosocial needs. There are several reasons behind changing a patient’s treatment modality, and the consequences of each decision should be evaluated, considering both short- and long-term benefits and risks. Dialysis modality transition is not only to allow for technical optimization or improved patient survival, the patient’s experience associated with the transition should also be taken into account. Transition should not be considered as treatment failure, but rather as an expected progression in the patient’s treatment options.