Perspective from Paul Komenda, MD, FRCPC, MHA
Disclosures: The authors report no relevant financial disclosures.
June 21, 2021
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Care burden, lack of social support linked to exit from home hemodialysis programs

Perspective from Paul Komenda, MD, FRCPC, MHA
Disclosures: The authors report no relevant financial disclosures.
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Researchers from the University of Calgary identified reasons patients did not complete training for home hemodialysis, as well as potential causes for exiting the therapy after training was completed.

The primary reasons were psychosocial, leading Bailey Paterson, MD, HBSc, and colleagues to recommend home hemodialysis (HHD) programs develop “targeted interventions that meet [patients’] support needs.”

Technique failure with home hemodialysis
Infographic content was derived from Paterson B, et al. Can J Kidney Health Dis. 2021;doi:10.1177/20543581211022195.

According to Paterson and colleagues, although HHD is cost-effective in the longer term, estimations have shown it can take between 9 and 12.6 months on the therapy to achieve cost savings; during this time, some patients may exit the program, yet contributing factors have not been previously documented.

“The main objective of this study is to explore the reasons behind patient exit from HHD in the Alberta Kidney Care South (AKC-S) program,” the researchers wrote. “Understanding reasons why patients leave HHD and the timing of these events will facilitate the development of targeted interventions and effective resource allocation to reduce modifiable reasons for patient exit. This knowledge will also be useful to understand the high patient turnover in HHD and allow the program to make accurate growth forecasts.”

Using the AKC-S electronic medical record, researchers identified 167 patients who started training for HHD between 2013 and 2020 (68% were men; mean time on dialysis was 1.67 years; 55.8% had a central venous catheter). Researchers considered reasons for training failure, time spent on home hemodialysis upon completion of training and reasons for exiting the therapy (early exit was defined as exit from HHD prior to 12 months).

Training to home-based therapy

Total training time was 6 weeks for all patients, with 12% failing training (occurring at a median of 3.1 weeks). Patients who failed training (and, therefore, did not initiate hemodialysis treatments at home) were more likely to have two or more comorbidities (most notably, congestive heart failure) and to be un-married compared with those who successfully completed training. The most common reasons patients left the training program were categorized as “patient preference” (eg, excessive workload, lack of energy or close proximity to in-center dialysis facility) or “medical” (eg, chronic pain or access site infection).

For the 88% of patients who completed training, 47.9% remained on HHD at the end of the study period. The median time on HHD was 21 months, which the researchers noted exceeded “the 12-month threshold to achieve cost savings with [in-center hemodialysis] ICHD.”

The most common reasons for exit from HHD were transplant (21%), technique failure (14.4%) and mortality (4.8%).

Psychosocial, medical concerns

Looking specifically at patients who experienced technique failure (which, in nearly half of cases, occurred within the first 12 months of home treatments), Paterson and colleagues discovered psychosocial reasons contributed to earlier exit from HHD; these included loss of caregiver support, fear of losing consciousness on dialysis due to intradialytic hypotension and loss of residence/eviction from home.

Further, because technique failure was associated with the presence of coronary artery disease, a chronic pulmonary condition and diabetes, researchers suggested patients with these conditions might be at greatest risk for leaving HHD programs.

“Increased support from the HHD program in terms of providing home visits, increased access to emotional and mental health supports, peer support and perhaps even a HHD assist program akin to what has been established in [peritoneal dialysis] PD could help reduce some anxiety, prevent caregiver burnout and subsequent early exits and/or training failure from HHD,” Paterson and colleagues wrote of the findings. “It may also be that the demands that a HHD program places on patients become onerous over time with increasing safety and adherence concerns manifesting later (19 months). Given these observations, perhaps programs should review their demands on patients with an eye to reduce the patient burden of care and workload.”

To these ends, the researchers recommend HHD programs focus on reducing frequency of blood work, outsourcing the dialysate and water sampling to technicians and reducing the number of in-person clinic visits by increasing virtual visits.

“Home hemodialysis is a cost-effective modality that enhances patients’ quality of life in kidney failure treated with hemodialysis,” Paterson and colleagues concluded. “However, significant turn-over occurs, and many patients do not successfully complete training ... Interventions are required at the screening, training, and maintenance at home phases in order to reduce attrition and enhance success rates of patients on HHD. Future research that engages and collaborates with patients and caregivers is needed in order to identify and prioritize their needs to address the current gaps in care for patients on home dialysis.”