Pathways to improve nephrologist comfort in managing patients on in-center or home self-care dialysis

In end-stage kidney disease (ESKD), patient engagement and empowerment are associated with improved survival and complications. However, patients lack education and confidence to participate in self-care. The development of in center self-care hemodialysis can enable motivated patients to allocate autonomy, increase satisfaction and engagement, reduce human resource intensiveness, and cultivate a curiosity about home dialysis. In this review, we emphasize the role of education to overcome barriers to home dialysis, strategies of improving home dialysis utilization in the COVID 19 era, the significance of in-center self-care dialysis (e.g., cost containment and empowering patients), and implementation of an in-center self-care dialysis as a bridge to home hemodialysis (HHD).     

The path to a paradigm shift in hemodialysis

About 1 out of 4 American conventional dialysis patients die in the first year and 3 out of 5 die within 5 years with no favorable trend in sight. Largely ignored in practice is the evidence accumulated over decades that longer, more frequent dialysis can immediately slash this grim result in half or more. Pierratos has called for a paradigm shift—a disruptive change—in dialysis practice from conventional treatment to daily nocturnal dialysis, performed at home, to realize this dramatic improvement. We examine here how such a paradigm shift might be brought about and suggest that changes in 3 perspectives must occur. First, new dialysis guidelines must be recast from the old goal of minimally adequate to a new goal of best possible . Second, the body of dialysis research must be interpreted through the lens of best possible patient survival and well being, and the near-impossibility of demonstrating dialysis survival advantage through randomized clinical trials must be acknowledged. Finally, dialysis modality must be seen as, most importantly, a survival and well-being choice, not merely a "Lifestyle" choice; hence, it must be the nondelegatable responsibility of the physician, not dialysis center personnel, to advise and prescribe. Many old perspectives, which might stand in the way of this sorely needed paradigm shift are also examined. These old perspectives make up a fabric of excuses that has delayed—and, if not discarded, will continue to delay—progress toward a survival and well-being outlook for dialysis patients just as favorable as might be achieved through kidney transplant.     

What limits the expansion of self‐care dialysis at home?

Self-care dialysis at home, whether peritoneal dialysis or hemodialysis, is more cost-effective than in-center dialysis and treatment outcome is at least comparable. Still, both self-care modalities are considered underutilized and we wished to identify the perceived reasons for this underutilization among nephrology professionals. A questionnaire was distributed at 5 international nephrology meetings in 2006. Questions addressed the most important stakeholders and the most important issues for patients and nephrology professionals to enable the expansion of self-care dialysis and commonly mentioned barriers were given as alternative responses. The proportion of patients considered suitable for self-care was also investigated. Seven thousand responses were collected. The listed stakeholders, i.e., health care and reimbursement authorities, nurses and physicians, and finally patients and their families, are considered approximately equally important for the process. Nephrology professionals feel that patient motivation for choosing and performing self-care dialysis is the strongest driver. The need for dedicated resources for self-care is judged to be vital for the expansion of this modality of treatment. Thirty-two percent of incident patients are considered able to perform self-care dialysis at home. This international survey among 7000 nephrology professionals has identified patient motivation as one of the strongest drivers of self-care dialysis at home. The need for dedicated resources for the staff to devote time to developing such motivation is given as one of the major reasons for the slow adoption. Under ideal conditions, it is felt that one-third of all patients starting dialysis can be trained to perform self-care dialysis.     

Patient experiences and preferences on short daily and nocturnal home hemodialysis

Quotidian/intensive hemodialysis (short daily and nocturnal) has variable effects on health‐related quality of life (HRQOL) as measured by standard HRQOL tools. We sought to understand the perceived benefits and limitations of quotidian dialysis by interviewing patients who had switched from conventional to home quotidian dialysis. We used a qualitative, phenomenological approach to explore the perceived benefits of quotidian dialysis from 10 patients using either short daily or nocturnal hemodialysis at a tertiary health care center in London, Canada. The patients varied in gender, age, employment status, home support, physical capacity, primary cause of kidney disease, previous forms of renal replacement therapy, and level of education. Four major themes emerged: (1) improvement in physical and mental well‐being including better blood pressure and concentration, (2) increased control over patient's own life including time availability, choosing when to dialyze, and dialyzing at home, (3) decreased perception of being sick including returning to regular employment and avoiding sicker patients who must have in‐center dialysis, and (4) identification of the competencies and supports required for quotidian dialysis including ability to provide self‐care, supportive family, and medical support. Our findings suggest when patients' willingness and physical ability to use quotidian dialysis are coupled with education and support systems to assist patients' and families' self‐directed care, patients qualitatively perceive benefits of both increased physical and mental health, both measures of health‐related quality of life.     

Thyroid function in end stage renal disease and effects of frequent hemodialysis

Introduction: End‐stage renal disease (ESRD) is associated with perturbations in thyroid hormone concentrations and an increased prevalence of hypothyroidism. Few studies have examined the effects of hemodialysis dose or frequency on endogenous thyroid function. Methods: Within the Frequent Hemodialysis Network (FHN) trials, we examined the prevalence of hypothyroidism in patients with ESRD. Among those with endogenous thyroid function (without overt hyper/hypothyroidism or thyroid hormone supplementation), we examined the association of thyroid hormone concentration with multiple parameters of self‐reported health status, and physical and cognitive performance, and the effects of hemodialysis frequency on serum thyroid stimulating hormone (TSH), free thyroxine (FT4), and free tri‐iodothyronine (FT3) levels. Conventional thrice‐weekly hemodialysis was compared to in‐center (6 d/wk) hemodialysis (Daily Trial) and Nocturnal (6 nights/wk) home hemodialysis (Nocturnal Trial) over 12 months. Findings: Among 226 FHN Trial participants, the prevalence of hypothyroidism was 11% based on thyroid hormone treatment and/or serum TSH ≥8 mIU/mL. Among the remaining 195 participants (147 Daily, 48 Nocturnal) with endogenous thyroid function, TSH concentrations were modestly (directly) correlated with age (r = 0.16, P = 0.03) but not dialysis vintage. Circulating thyroid hormone levels were not associated with parameters of health status or physical and cognitive performance. Furthermore, frequent in‐center and nocturnal hemodialysis did not significantly change (baseline to month 12) TSH, FT4, or FT3 concentrations in patients with endogenous thyroid function. Discussion: Among patients receiving hemodialysis without overt hyper/hypothyroidism or thyroid hormone treatment, thyroid indices were not associated with multiple measures of health status and were not significantly altered with increased dialysis frequency.     

Dialysis education and options for late presenters—An ongoing dilemma

Pre-dialysis education forms a crucial part of dialysis preparation. Acute start dialysis patients often commence and remain on in-center hemodialysis (ICHD) without the benefit of an informed decision making process for kidney replacement therapy options. The aim of this review is to evaluate the evidence surrounding methods of education provision to the acute dialysis start population and their associated outcomes. Publications have described a holistic education pathway with multimedia provision of information and interactive experiences. One or more trained specialist nurses provided information over 3–5 sessions. Formal education was mostly initiated as an inpatient. 86%–100% of acute start dialysis patients are initiated and remain on ICHD. Following formal education, 21%–58% of patients chose peritoneal dialysis (PD), 10%–24% home hemodialysis, 33%–58% ICHD. This brings the number of patients maintained on an independent form of dialysis similar to the planned dialysis start population. Patients commenced on PD without needing temporary hemodialysis, hence avoided complications associated with such. Patients aged under 75 (p < 0.0001) and males (p = 0.006) were more likely to be influenced by education to select PD. The adjusted 5 year survival rates among discharged patients were similar between home and ICHD groups (73% vs. 71% respectively), with a comparable age of death. A targeted education program in the acute dialysis start population has proven to be feasible. Adaptations are likely required for each center; however, various methods have been shown to be effective, with an increased number of patients choosing an independent dialysis modality when given the choice.     

Patient preferences for in-center intense hemodialysis

There is a lack of data on patient preferences for intense hemodialysis (IHD). In this study, we conducted a cross-sectional survey to identify patient preferences and patient-centered barriers for IHD. A questionnaire on preferences and anticipated barriers, anticipated benefits, and quality of life for three in-center IHD schedules (daytime 2 hr six times/week [DHD], nocturnal 8 hr three times/week [ND3], and nocturnal 8 hr six times/week [ND6]) was administered to 100 chronic hemodialysis patients. A majority of patients (68%) were willing to undergo DHD for symptomatic benefits or increase in survival. An increase in energy level (94%) and improvement in sleep (57%) were the most common potential benefits that would justify DHD, but only 19% would undergo DHD for an increase in survival of < or =3 years. Only 20% and 7% would consider ND3 and ND6, respectively. The most common reported barriers were inadequate time for self (50%) and family (53%), followed by transportation difficulties (53%). Most patients would undergo DHD for symptomatic or survival benefits, but not ND3 or ND6. Disruption of personal time, however, is an important consideration. Success of DHD program would depend on arrangements for transportation to dialysis unit.     

Short and long nightly hemodialysis in the United States

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.     

The advantages and disadvantages of home hemodialysis

In Australia, 12% of the hemodialysis population dialyze at home. Until recently, the majority of these patients dialyzed for similar hours to those in satellite dialysis. However, in the past 5 years there has been a new departure such that in many centers the concept of home hemodialysis is now synonymous with extended hours dialysis. Registry data supports the concept that increased frequency and duration of dialysis may result in improved patient survival and a reduction in cardiovascular risk profile. It is hoped, therefore, that the long recognized survival benefit observed in home hemodialysis patients may be further augmented by the swing to extended hours dialysis in this patient population. In addition to the physiological benefits of extended hours home dialysis, there are clear quality of life, social, and economic advantages associated with dialyzing at home. There are however a number of perceived disadvantages to home hemodialysis including the application and time commitment required for training, the potential for relationship strain or "burnout," and reluctance to "hospitalize" the home. Overall, however, in this new era of extended hours dialysis, the advantages both physiological and lifestyle of home hemodialysis far outweigh the disadvantages.     

Role of peritoneal dialysis in the era of the resurgence of home hemodialysis

In recent years, there has been a resurgence of home hemodialysis (HHD) therapies. Given the small percentage of prevalent patients in the United States currently on home dialysis, an appropriate question is: What is the role of peritoneal dialysis (PD) in this era? Data suggest that in centers that are promoting the growth of HHD, their PD programs also tend to be very active. Furthermore, our experience and other data suggest that one should not worry about cannibalizing PD in order to grow HHD. Most HHD patients come from in‐center hemodialysis or those patients transitioning from PD to another therapy. In fact, data suggest that in order to promote the growth of HHD, a certain minimal infrastructure is needed in terms of staff. An active PD program not only supports a robust infrastructure that allows for HHD growth but also fosters profitability of a home program.     

A primer for the prescription of short-daily and nocturnal hemodialysis

More frequent and intensive hemodialysis (HD) schedules continue to garner interest internationally. Two dominant regimens have emerged, namely short-daily and nocturnal HD. A growing body of observational data suggests that these regimens allow more rigorous control of biochemical and physical parameters when compared with conventional HD. This review describes the methodology used in providing more frequent or sustained HD both in center and at home, and attempts to provide a physiological rationale for the practices described in the current literature.     

6 Month Experience with 1 Nurse Training 2 Patients Together for Nightly Home Hemodialysis

Purpose:  Nocturnal home hemodialysis (NHHD, 6–7 times weekly 6–9 h) results in better clinical outcome than conventional 3 times weekly hemodialysis. A good training program for patient and partner is a prequisite for success. We developed a training course for patients and partners.
Methods:  Since December 2001, we trained 20 patients and their partners to perform NHHD in 2 succeeding groups. The first group, consisting of 15 patients and their partners, started a NHHD pilot study. During this pilot study, we improved the training course. The second group of 5 were trained with this improved program. All 5 participants were home hemodialysis patients for over 1 month before starting the NHHD course. First, they learned how to handle the single needle system. Then, they performed single needle hemodialysis for 2 weeks at home. This was followed by an in-center NHHD training, consisting of 4 conventional day-time and 3 long (8 h) nocturnal dialysis treatments. Main targets during this training period are to learn to deal with safety precautions, online monitoring, and special machine features, and to check biochemistry and heparinization during long dialysis. 1 month after the training we evaluated the course with all participants.
Results:  For 9 of 15 couples in the first group, the training appeared to be exhausting. Stress factors were an overloaded program and too little experience with several new skills including needle technique before starting NHHD. The second group started the NHHD training 2 weeks after the single needle training. This second group was pleased with the training protocol.
Conclusion:  The training course for NHHD should not be overloaded. Patients need time to learn new skills before starting NHHD.     

Insights into nephrologist training, clinical practice, and dialysis choice

There is variable emphasis on dialysis-specific training among US nephrology fellowship programs. Our study objective was to determine the association between nephrology training experience and subsequent clinical practice. We conducted a national survey of clinical nephrologists using a fax-back survey distributed between March 8, 2010 and April 30, 2010 (N = 629). The survey assessed the time distribution of clinical practice, self-assessment of preparedness to provide care for dialysis patients at the time of certification examination, distribution of dialysis modality among patients, and nephrologists' choice of dialysis modality for themselves if their kidneys failed. While respondents spent 28% of their time caring for dialysis patients, 38% recalled not feeling very well prepared to care for dialysis patients when taking the nephrology certification examination. Sixteen percent obtained additional dialysis training after fellowship completion. Only 8% of US dialysis patients use home dialysis; physicians very well prepared to care for dialysis patients at the time of certification or who obtained additional dialysis training were significantly more likely to provide care to home peritoneal dialysis patients. Even though 92% of US dialysis patients receive thrice weekly in-center hemodialysis, only 6% of nephrologists selected this for themselves; selection of therapy for self was associated with dialysis modalities used by their patients. Nephrology training programs need to ensure that all trainees are very well prepared to care for dialysis patients, as this is central to nephrology practice. Utilization of dialysis therapies other than standard hemodialysis is dependent, in part, on training experience.     

The ideal home hemodialysis machine

Daily home hemodialysis (HD) patients have a much superior survival rate than patients on regular, 3 times a week in-center HD or on peritoneal dialysis. Present-day HD machines are unsuitable for use at home by patients. We present our concept of the ideal home HD machine that allows daily short and long HD, does all the work preparing for and cleaning up after dialysis, has an intravenous infusion system controlled by the patient, needs no systemic anticoagulation, and teaches and interacts with the patient during dialysis. To fulfill these functionalities, the dialyzer and blood tubing must be integrated with the machine and replaced less often than monthly, the machine must be capable of at least 200 L/week of hemodiafiltration, prepare all fluids necessary between and during dialyses, and all the components and fluids must be much beyond ultrapure.     

Hyperprolactinemia in end‐stage renal disease and effects of frequent hemodialysis

Introduction: End‐stage renal disease is associated with elevations in circulating prolactin concentrations, but the association of prolactin concentrations with intermediate health outcomes and the effects of hemodialysis frequency on changes in serum prolactin have not been examined. Methods: The FHN Daily and Nocturnal Dialysis Trials compared the effects of conventional thrice weekly hemodialysis with in‐center daily hemodialysis (6 days/week) and nocturnal home hemodialysis (6 nights/week) over 12 months and obtained measures of health‐related quality of life, self‐reported physical function, mental health and cognition. Serum prolactin concentrations were measured at baseline and 12‐month follow‐up in 70% of the FHN Trial cohort to examine the associations among serum prolactin concentrations and physical, mental and cognitive function and the effects of hemodialysis frequency on serum prolactin. Findings: Among 177 Daily Trial and 60 Nocturnal Trial participants with baseline serum prolactin measurements, the median serum prolactin concentration was 65 ng/mL (25th–75th percentile 48–195 ng/mL) and 81% had serum prolactin concentrations >30 ng/mL. While serum prolactin was associated with sex (higher in women), we observed no association between baseline serum prolactin and age, dialysis vintage, and baseline measures of physical, mental and cognitive function. Furthermore, there was no significant effect of hemodialysis frequency on serum prolactin in either of the two trials. Discussion: Serum prolactin concentrations were elevated in the large majority of patients with ESRD, but were not associated with several measures of health status. Circulating prolactin levels also do not appear to decrease in response to more frequent hemodialysis over a one‐year period.     

The Middle Molecule Hypothesis Revisited. Should Short,Three Times Weekly Hemodialysis Be Abandoned?

When the middle molecule (MM) hypothesis was formulated in 1975, no MM had yet been identified as a uremic toxin. Meanwhile, the birth and implementation of the Kt/V_urea concept gained wide acceptance and has remained the world standard for assessing dialysis adequacy. However, over the past 20 years, accumulating evidence has made it clear that MM's are important uremic toxins, and that the dose of dialysis based on removal of small molecular substances does not protect against excessive hemodialysis mortality, morbidity, or the presence of uremic signs and symptoms. These poor results are, in one way or another, linked to the accumulation of MM's and other substances behaving like MM's, such as phosphate. Dialysis schedules yielding the best clinical results, such as longer dialysis and more frequent dialysis, favor increased removal of middle molecular substances. The observation that short daily dialysis is giving results similar to long nocturnal quotidian dialysis supports early observations that the volume from which middle molecular substances are extracted mainly by hemodialysis is small (about as large as the extracellular volume), and that transfer of MM's from cells to extracellular fluid is very slow. This behavior of MM's is markedly different from that of small molecular substances, which are more rapidly transferred from intracellular to extracellular compartments and are more readily extracted from total body water during hemodialysis. In order to achieve even minimum adequate dialysis, it is now scientifically validated that toxic MM's must be removed in larger amounts than currently attained. This can only be accomplished by long dialysis sessions with a 3‐times per week schedule or more frequent dialyses. Five hours 3 times per week represents the absolute minimum treatment. Dialy sis 6 to 7 times per week is the ideal schedule for patients who are willing to commit the time and effort in exchange for maximum well‐being and long survival.     

Ultrapure dialysis fluid: Improving conventional and daily dialysis

Dialysis fluid of standard quality contains a certain amount of bacteria and endotoxin. This has been considered acceptable because the dialysis membrane was believed to be a protective barrier to blood. However, improved methods for detection of cellular activation have demonstrated that bacterial products in the dialysate may stimulate monocytes to produce cytokines with most dialysis membranes. Ultrapure dialysis fluid is practically free from bacteria and endotoxin (< 0.1 CFU/mL and < 0.03 EU/mL) and can be prepared from standard‐quality dialysis fluid using a single step of controlled ultrafiltration. The European guidelines for hemodialysis (HD) set the use of ultrapure dialysis fluid as the goal for all dialysis modalities. Several clinical studies report improved inflammatory status in HD patients when ultrapure dialysis fluid is used, compared with standard‐quality dialysate. The benefits include less frequent occurrence of carpal tunnel syndrome, lower C‐reactive protein values, reduced need for erythropoietin, better nutritional status, and even better preservation of residual renal function. For patients on daily dialysis, dialysate quality is especially important because such patients are often treated at home where quality control of incoming water may be less rigorous, and increased treatment frequency leads to exposure to larger volumes of dialysis fluid than with conventional dialysis. The use of ultrapure dialysis fluid together with low‐complement‐activating membranes maximizes the biocompatibility of a dialysis treatment, a goal of treatment, although there is a lack of evidence to date supporting a beneficial effect on mortality. From a physiologic point of view the reduced inflammatory stimulus that can be achieved with ultrapure dialysis fluid is highly desirable. In addition, achieving ultrapure dialysis fluid is realistic, because today it can be practically and economically prepared using modern equipment and applying appropriate microbiologic surveillance techniques.