Knowledge of Home Dialysis Among Inner‐City Satellite Hemodialysis Patients

There is limited use of home renal replacement therapies in the U.S.A. One percent of dialysis patients are on home hemodialysis (HHD) and only 9% undergo peritoneal dialysis (PD). In an effort to better understand this, 161 satellite hemodialysis patients in 6 units in Brooklyn were surveyed. Forty‐eight percent of patients were women, 86% were black, 5% white, 8% Hispanic, and 1% other. Mean age was 49.4 years (range 22 – 69 years). Etiology of renal disease was hypertension (41%), diabetes mellitus (31%), polycystic kidney disease (3%), systemic lupus erythematosus (4%), and other or unknown (21%). Patients were queried about knowledge of and attitudes toward home therapies. Seventy‐nine percent of patients knew of home dialysis. The source of this information was the nephrologist (59%), the social worker (14%), a nurse (8%), other patients (4%), and other sources (15%). Only 10% of patients had ever considered HHD. Fifty‐four percent were afraid to do self‐care at home and 35% were not interested. Surprisingly, only 3% felt they had no reliable helper and 8% felt that their housing was not suitable. Similarly, 78% of patients had been spoken to about PD, but only 11% had considered it. Forty‐one percent were afraid of doing self‐care on PD, and 45% were not interested. We conclude that, although the majority of patients in six inner‐city dialysis units had heard of home dialysis, only a small number ever considered it. As many patients were afraid of doing home therapy, better education about the risks and benefits needs to be disseminated.     

In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

A Composite Index of Compliance for Chronic In‐Center Hemodialysis Patients

We developed a composite compliance index as the sum of the compliance scores for interdialytic weight gain (IDWG), pre‐dialysis serum potassium and phosphorus concentrations (each scored from zero to 3, with 3 indicating the poorest compliance), and skipping hemodialysis sessions (scored from zero to 9, with 9 indicating the poorest compliance). We used this composite score to prospectively evaluate compliance in 25 prevalent hemodialysis patients over a period of 1 year. We then followed these patients for another 3.5 years. The patients studied were divided into two groups: group A (poor compliance) consisted of 9 subjects with composite score ≥ 9 (13.2 ± 3.2); group B (better compliance) consisted of 16 subjects with composite score < 9 (4.7 ± 1.8). Age, duration of hemodialysis, and frequency of diabetes mellitus did not differ between the groups. Group A contained higher fractions of subjects with history of alcoholism (66.7% vs 12.5%, p = 0.010), other substance addiction (44.4% vs 0%, p = 0.010), and severe psychosocial problems (88.9% vs 18.8%, p = 0.002). Mean survival from the beginning of observation, estimated by actuarial life‐table survival analysis, was 1.19 years in group A and 2.60 years in group B (p = 0.0265). A composite compliance index incorporating domains indicating adherence to diet, medications, and dialysis schedule identified other behavioral problems in poorly compliant patients. Hemodialysis patients characterized by this composite index as poorly compliant had shortened survival.     

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.     

A Brief History of Daily Hemodialysis

Daily hemodialysis has been in uninterrupted practice since its introduction in California in 1967. Early trials were stopped for technical, logistical, and economical problems, but a rapidly increasing number of centers now perform it on close to 200 patients, either as long nightly or short daytime hemodialysis. Increasing the frequency of dialysis appears much more important in improving patient well-being than increasing the Kt/V dose, and patients quickly experience much more vigor, energy, and improved quality of life when starting daily hemodialysis. Blood pressure improves, and medications can often be discontinued. Similarly, the need for erythropoietin decreases, and nutrition and dry body mass increase. While the cost of dialysis increases, the total cost for a patient decreases as medications and hospitalizations decrease. Technical innovation will solve the logistical problems by letting a machine do the labor necessary to begin and end a dialysis session. Access problems have decreased for native fistula, and the other access types have not been studied enough.     

Forty‐five years on home hemodialysis,a case of exceptional longevity

End‐stage renal disease is associated with dismal long‐term survival in general. Home hemodialysis (HHD) has been advocated as a modality affirming better quality of life and longer survival. We report a 62‐year‐old Caucasian female with end‐stage renal disease who has been exclusively on HHD for a total of 45 years, utilizing various platforms over the years. She has been one of the first home dialysis patients of the founding father of renal dialysis in the state of Mississippi, John D. Bower and cared by him throughout his career. Throughout this period, her life bore witness to the evolving technology of dialysis accesses, platforms, and evolution of HHD in its entirety. After review of the literature, we find that the longest vintage time on HHD documented to date was around 35 years. This extraordinary longevity bears testimony to the extraordinary self‐motivation of the patient, the dedication of her providers and the true potential of HHD in motivated subjects.     

Determinants of training and technique failure in home hemodialysis

Home hemodialysis (HHD) has clinical and economic advantages compared with in‐center conventional hemodialysis. Many health systems wish to broaden the population to which this modality can be successfully offered. However, determinants of successful HHD training and technique survival are unknown. We hypothesize that both medical and social factors play a role when patients fail to successfully adopt HHD. We examined characteristics of consecutive patients who initiated training for HHD between 2003 and 2011. Patients were classified as “failure” if they failed to complete HHD training or experienced technique failure (TF) within the first year of treatment. Remaining patients were classified as “success.” One hundred seventy‐seven patients initiated HHD training. In the “failure” group (n = 32), 24 did not finish training and 8 had TF. In the “success” group (n = 145), 65 (45%) patients remained on NHD, 49 (34%) discontinued HHD because of renal transplantation and 21 (14%) because of death, while only 10 (7%) eventually transferred to another dialysis modality. In a multivariable logistic regression analysis, the strongest predictors of “failure” were end‐stage renal disease because of diabetes (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4–10.3, P = 0.008) and use of rental housing (OR 3.1, 95% CI 1.3–6.0, P = 0.01). Both medical and social factors are associated with failure to adopt HHD. Enhanced supports or a customized education strategy for these vulnerable patients should be considered.     

Understanding barriers to home‐based and self‐care in‐center hemodialysis

Despite superior outcomes and lower associated costs, relatively few patients with end‐stage renal disease undergo self‐care or home hemodialysis. Few studies have examined patient‐ and physician‐specific barriers to self‐care and home hemodialysis in the modern era. The degree to which innovative technology might facilitate the adoption of these modalities is unknown. We surveyed 250 patients receiving in‐center hemodialysis and 51 board‐certified nephrologists to identify key barriers to adoption of self‐care and home hemodialysis. Overall, 172 (69%) patients reported that they were “likely” or “very likely” to consider self‐care hemodialysis if they were properly trained on a new hemodialysis system designed for self‐care or home use. Nephrologists believed that patients were capable of performing many dialysis‐relevant tasks, including: weighing themselves (98%), wiping down the chair and machine (84%), clearing alarms during treatment (53%), taking vital signs (46%), and cannulating vascular access (41%), but thought that patients would be willing to do the same in only 69%, 34%, 31%, 29%, and 16%, respectively. Reasons that nephrologists believe patients are hesitant to pursue self‐care or home hemodialysis do not correspond in parallel or by priority to reasons reported by patients. Self‐care and home hemodialysis offer several advantages to patients and dialysis providers. Overcoming real and perceived barriers with new technology, education and coordinated care will be required for these modalities to gain traction in the coming years.     

The use of vascular access audit and infections in home hemodialysis

Vascular access‐related infection is an important adverse event in home hemodialysis (HHD). We hypothesize that errors in self‐cannulation or manipulation of dialysis vascular access are associated with increased incidence of access‐related infection. We conducted a retrospective cohort study of all prevalent HHD patients at the University Health Network. All vascular access‐related infections were recorded from 2006 to 2013. Errors in dialysis access were ascertained by nurse‐administered vascular access checklist. Ninety‐two patients had completed at least one vascular access audit. Median HHD vintage was 2.3 (0.9–5.0) years in patients with appropriate vascular access technique and 5.8 (1.5–9.4) years in patients with erroneous vascular access technique. The overall rate of infection between patients with and without appropriate vascular access technique was similar (0.27 and 0.28 infections per year, P = 0.166). Among patients who were identified with errors in dialysis access manipulation, patients with five or more errors were associated with higher rate of access‐related infection (mean of 0.47 vs. 0.16 infection per patient‐year, P < 0.001). The use of vascular access audit is a feasible strategy, which can identify errors in vascular access technique. Patients with a longer median HHD vintage are associated with higher risk of inappropriate vascular access technique. Patients with multiple errors in vascular access technique are associated with a higher risk of dialysis access‐related infection. Prospective evaluation of the impact of vascular access audit on adverse vascular access events is warranted.     

On‐line hemodiafiltration at home

Survival with online hemodiafiltration (OL‐HDF) is higher than with hemodialysis; frequent hemodialysis has also improved survival and quality of life. Home hemodialysis facilitates frequent therapy. We report our experience with 2 patients with stage 5 CKD who started home hemodialysis with OL‐HDF in November 2016. After a training period at the hospital, they started home hemodialysis with OL‐HDF after learning how to manage dialysis monitors and how to administer water treatment. We used the “5008‐home” (FMC^©) monitor, and the Acqua C^© (Fresenius Medical Care) for water treatment. Water conductivity was always checked before and during dialysis sessions and was always 2.5 to 3 mS/cm. Water cultures always fulfilled the criteria for ultrapurity. As far as we know, this is the first report on patients receiving OL‐HDF at home. The technique proved to be safe and valid for renal replacement therapy and transfers the benefits of hospital convective therapy to the home setting. Future data will enable us to determine whether survival has also improved.     

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.     

Blood Access Outcomes Associated with Short Daily Hemodialysis

With the growing number of reports that daily hemodialysis (DHD) improves clinical outcomes and quality of life, there has been increased interest in the effects of more frequent venipunctures on blood accesses. Since 1996, we have converted 30 patients (27 in‐center, 3 home) from conventional 3/week dialysis to short, daily, 6/week dialysis (sDHD). Twenty‐five patients started for medical indications. End‐stage renal disease (ESRD) causes were diabetes mellitus (in 7), hypertension (6), glomerulonephritis (8), hereditary nephritis (2), and other (7). Mean (±SD) age was 57 ± 16 years. Patients had an average of 3.8 major comorbidities in addition to ESRD. Thirty patients were followed on sDHD for 388 patient‐months: 9 patients died after 4.2 ± 6.7 months, 3 were transplanted at 5.4 ± 2.2 months, and 3 were disenrolled at 9.3 ± 10.5 months. Fifteen patients remain on sDHD at 20.4 ± 14.1 months. Access problems for the 12 months prior to sDHD were compared to those that occurred while the patient was on sDHD. Problems were tracked by access type. There were 40 different accesses in 30 patients with a cumulative 28.07 access‐years pre‐DHD; 24 of these accesses were artificial bridge grafts (ABG) of either polytetrafluoroethylene or bovine material. There were 27 access problems pre‐DHD, or 0.962 problems per access‐year. On sDHD these same 30 patients had 41 accesses for 34.44 access‐years; 23 of these were ABGs. There were 31 access problems or 0.900 problems per access‐year. There were no significant differences in access problems comparing pre‐DHD with on‐sDHD, either in aggregate or when analyzed by access type. After 39 months of observation, there does not appear to be an increase in blood access problems when patients are converted from conventional dialysis to sDHD.     

Hemodialysis for infants,children, and adolescents

Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital‐based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.     

Association between patient psychosocial characteristics and receipt of in‐center nocturnal hemodialysis among prevalent dialysis patients

Introduction: Compared to traditional in‐center hemodialysis (HD), in‐center nocturnal dialysis (INHD) is characterized by longer sessions and nighttime administration, which may lead to better outcomes for some patients. Given the importance of patient choice in the decision to initiate INHD, we explored associations between patients’ psychosocial characteristics and their receipt of INHD. Methods: Among hemodialysis patients at a medium‐sized dialysis organization, we identified INHD patients as those for whom ≥80% of dialysis sessions were INHD sessions—starting at 6:30 pm or later and lasting ≥5 hours—over the 3 months (≥20 sessions total) after their first INHD session. We extracted dialysis session data from electronic medical records and psychosocial data from social worker assessments. We tested associations of patients’ psychosocial characteristics—as well as demographic and clinical characteristics—with INHD receipt among all hemodialysis patients (INHD and HD) in bivariate analyses and multivariable logistic regression models. Findings: Among 759 patients with complete data, we identified 47 (6.2%) as INHD patients. On average, these patients were more likely than HD patients to be employed (full‐time 10.6% vs. 5.2%; part‐time 17.0% vs. 4.2%; P < 0.001), and they were significantly less likely to require ambulatory assistance (14.9% vs. 39.6%, P < 0.001). In multivariable regressions, we found that part‐time employment (versus being unemployed) was associated with a 7.1 percentage‐point higher likelihood of being an INHD patient (P = 0.01), and the negative association with ambulatory assistance needs approached statistical significance (P = 0.056). No other psychosocial factors included in this main regression analysis were statistically significantly associated with INHD patient status. Discussion: Researchers comparing the outcomes of patients undergoing INHD versus other treatment modalities will need to account for differences in employment status—and other factors like requiring ambulatory assistance and age which may predict the ability to work—between INHD users and comparison patients to avoid bias in estimates.     

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.     

Experience With Nocturnal Hemodialysis

In order to provide a highly efficient, long-duration form of hemodialysis, we developed nocturnal hemodialysis. Patients were dialyzed nightly at home for 8 – 10 hours, 6 – 7 nights/week. We kept the dialysate flow at 100 mL/min and the blood flow at 250 – 300 mL/min. Patients were monitored remotely from the hospital through a computer connection. An internal jugular line was used as an access. We have trained 12 patients over 30 months and have accumulated 160 patient-months worth of data. The patients tolerated the dialysis very well and slept through the night. There was a significant improvement in their sense of well-being. Nightly Kt/V was 0.99. Weekly removal of phosphate was two times as high and β ₂ -microglobulin four times as high as conventional hemodialysis. All patients have discontinued their phosphate binders and have increased their dietary phosphate and protein intake. Hypertension was controlled with fewer medications, and erythropoietin dosages decreased. Complications were infrequent and included catheter occlusion and infections. Reusing the dialyzers decreased the cost of the treatment to levels similar to continuous ambulatory peritoneal dialysis. Nocturnal hemodialysis represents a viable dialysis modality that combines high quality, low cost, and excellent tolerance.     

The marginal cost of satellite versus in-center hemodialysis

Background: Despite increasing numbers of patients receiving hemodialysis in satellite units (SHD), the economic aspects have not been widely explored. A cost analysis of SHD and in‐center hemodialysis (ICHD) from a societal perspective was performed to establish the efficiencies associated with shifting resources and patients from ICHD to SHD. Methods: Costs were classified as fixed or variable and placed into categories. The resources for operating a SHD unit are the sum of two components: total fixed costs (TFC) and average variable cost (AVC) times SHD patient volume (Q). Using the TFC of a specific‐sized SHD unit and the difference in AVC between ICHD and SHD the number of patients needed (Q) in the SHD unit for financial viability was determined. The formula TFC = (AVC_ICHD ? AVC_SHD) X Q was used to determine the number of patients (Q) needed in a specific‐sized SHD unit such that the yearly cost of SHD treatment would be the same as ICHD treatment. Results: Our results show that SHD fixed costs can be fully offset if the volume of SHD patients is seven per year in a six‐station unit. SHD costs were lower for nursing and physician fees. Therefore, ICHD care variable costs were $11,374 more per patient year. SHD patients would also have lower travel costs, a mean cost saving of $12,364 per year. Conclusion: SHD can result in significant savings both to the health‐care system and to patients. Using the cost categories and formula presented, the number of patients needed in a specific‐sized satellite unit to realize cost savings was determined for our program. We found that these savings can offset the fixed investment needed to operate a SHD unit at modest patient volumes.     

Patient mood flux on‐ and off‐hemodialysis

Mood in hemodialysis patients is most often evaluated off‐dialysis, possibly underestimating mood during dialysis. We compared mood in patients on‐ and off‐dialysis using the Positive and Negative Affect Schedule for 6 consecutive days. Initially, scores are normal, but subsequently positive affect falls below, and negative affect increases above, off‐dialysis values, suggesting increasing depression and anxiety, particularly in women. Quality‐of‐life questions confirm the effects of the dialysis session on mood. Prevalence and severity of depression evaluated off‐dialysis, or once only, may be underestimated, especially in women, because hemodialysis patients undergo mood swings centering on the dialysis session. Focusing insight on the dialysis session could improve coping among patients and caretakers.     

The History of Home Hemodialysis: A View From Seattle

Home hemodialysis was first used for the treatment of end-stage renal disease in the early 1960s, primarily as a means of reducing the cost of treatment. It was soon found to be an effective form of treatment that provided patient independence, greater opportunity for rehabilitation, and better survival. In 1973, when the Medicare End-Stage Renal Disease Program began, some 40% of all U.S. dialysis patients were on home hemodialysis, but since then the percentage of patients on this treatment has steadily decreased. There are several reasons for this, one in particular being the lack of availability of suitable equipment. There is now renewed interest in home hemodialysis sparked by the knowledge that new equipment specifically designed for this is being developed, that this is the modality with the best survival rate, greatest opportunity for adequate dialysis and best quality of life, and an interest in the use of daily (or nightly) home hemodialysis. Consequently, more than 30 years later, it appears that home hemodialysis may again become the preferred treatment for many more patients.     

The Case for Every‐Other‐Day Dialysis

Until daily dialysis becomes widely available, we believe that hemodialysis patients would benefit enormously from every‐other‐day dialysis (EODD), which may be implemented both by home patients and in centers. Benefits of EODD over the routine, three‐times‐weekly schedule would include decreased mortality after the weekend interval without dialysis; increased weekly dose of dialysis, resulting in better rehabilitation; and improved blood pressure control.