Perspective from Paul Komenda, MD, MHA, FRCPC
Disclosures: Lockridge reports no relevant financial disclosures. Co-authors Michael Krause, MD, is employed by Fresenius Medical Care North America, Waltham, Massachusetts and Martin Schreiber, MD is employed by DaVita Kidney Care, Denver, Colorado. See the full paper for disclosures on other authors of the paper.
August 03, 2020
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Home hemodialysis has clinical advantages in helping to meet Advancing American Kidney Health goals

Perspective from Paul Komenda, MD, MHA, FRCPC
Disclosures: Lockridge reports no relevant financial disclosures. Co-authors Michael Krause, MD, is employed by Fresenius Medical Care North America, Waltham, Massachusetts and Martin Schreiber, MD is employed by DaVita Kidney Care, Denver, Colorado. See the full paper for disclosures on other authors of the paper.
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Efforts by HHS through the Advancing American Kidney Health to improve dialysis care has put home dialysis in the spotlight as a safer, alternative therapy, per advocates in a recently published study.

But home hemodialysis (HHD), now used by less than 2% of the country’s outpatient dialysis providers, may be a better option for patients contemplating the road home.

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Source: Adobe Stock

“In this article, we do not aim to pit HHD and PD in a battle of home dialysis superiority, as some observational studies have endeavored,” Robert Lockridge Jr., MD, and colleagues wrote. “Both HHD and PD have important roles. Nevertheless, considering the pathophysiology of contemporary dialysis patients and the aims of the Advancing American Kidney Health initiative, we contend that widespread availability of intensive HHD is a necessary ingredient in a successful system.”

Home hemodialysis has several advantages, particularly in managing volume and reducing right ventricular systolic pressure (RSVP), two issues seen in patients who die on dialysis, the authors wrote. “In many patients, successfully managing volume and reducing RVSP will require the completion of three objectives: 1) achievement of true dry weight; 2) an increase in weekly hours of kidney replacement therapy, thereby meeting cumulative ultrafiltration demand, but at an ultrafiltration rate that is sufficiently low to avoid intradialytic complications; and 3) an increase in frequency of therapy, thereby decreasing both peak RVSP during interdialytic gaps.

Robert Lockridge

“These objectives are in reach with proper prescription of HHD, which is customizable to the individualized needs of patients,” they said.

If clinicians can bring blood pressure under control and see a reduction in primary and secondary left ventricular hypertrophy through the use of HHD, a “significant reduction” in the risks for cardiovascular death and hospitalization could occur, the authors said. “We also need to aim for symptom-free hemodialysis sessions, as numerous patients have loudly stated. Intensive HHD is one treatment that can address these needs.”

Increasing HHD use means patients need to hear about the modality and its benefits throughout their time on dialysis, the authors wrote. Methods of accomplishing that, the author wrote, include:

  • Patients initiating dialysis can access a transitional care unit, which educates patients on all modalities;
  • Prevalent hemodialysis patients “may participate in ‘trial run’ programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training,” the authors wrote. “In both models, perceived barriers to HHD, including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner, can be addressed in a supportive setting.”
  • Peritoneal dialysis patients who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (ie, from peritoneal dialysis to HHD).

“Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of dialysis patients,” the authors concluded. “With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of dialysis patients.”