Portal de Periódicos da CAPES

The Resurgence of Home Dialysis Therapies

2007; Elsevier BV; Volume: 14; Issue: 3 Linguagem: Inglês

10.1053/j.ackd.2007.03.005

1548-5609

John Moran,

Pharmacological Effects and Toxicity Studies

A recent resurgence of interest in home dialysis treatment is being driven by several factors, including (1) improved clinical outcomes associated with more frequent hemodialysis possible with home therapy; (2) patient preference for and greater convenience of home treatments; (3) lower treatment cost; (4) reduced staffing requirements; and (5) the availability of equipment specifically designed for self-care/home therapy. An important factor has been the recognition that the outcomes of peritoneal dialysis are similar to those of conventional in-center hemodialysis, and the advantages to the patient of utilizing different modalities during their dialysis “lifetime.” Additionally, regional home-dialysis programs that offer the full continuum of home therapies and provide comprehensive patient education and clinical support have been developed as a model for reinvigorating home therapies. A shift away from the current model with all too frequent late referral of patients for in-center treatment to a new model characterized by early intervention and home-based dialysis therapies will improve outcomes, while more effectively handling the growing population of patients requiring maintenance renal replacement therapy. A recent resurgence of interest in home dialysis treatment is being driven by several factors, including (1) improved clinical outcomes associated with more frequent hemodialysis possible with home therapy; (2) patient preference for and greater convenience of home treatments; (3) lower treatment cost; (4) reduced staffing requirements; and (5) the availability of equipment specifically designed for self-care/home therapy. An important factor has been the recognition that the outcomes of peritoneal dialysis are similar to those of conventional in-center hemodialysis, and the advantages to the patient of utilizing different modalities during their dialysis “lifetime.” Additionally, regional home-dialysis programs that offer the full continuum of home therapies and provide comprehensive patient education and clinical support have been developed as a model for reinvigorating home therapies. A shift away from the current model with all too frequent late referral of patients for in-center treatment to a new model characterized by early intervention and home-based dialysis therapies will improve outcomes, while more effectively handling the growing population of patients requiring maintenance renal replacement therapy. The number of patients with chronic kidney disease (CKD) who received maintenance dialysis in the United States grew to more than 335,000 in 2004.1U.S. Renal Data System: USRDS 2006 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2006Google Scholar In that year alone, nearly 95,000 patients began hemodialysis (HD), whereas only about 6,700 patients started peritoneal dialysis (PD). Within the next 3 years, more than 660,000 patients in the US will likely be undergoing treatment for end-stage renal disease (ESRD).2Remuzzi G. Schieppati A. Ruggenenti P. Clinical practice: Nephropathy in patients with type 2 diabetes.N Engl J Med. 2002; 346: 1145-1151Crossref PubMed Scopus (523) Google Scholar This epidemic of ESRD is anticipated in the face of the growing shortage of nephrology professionals available to deliver conventional in-center dialysis. This widening gap between the numbers of ESRD patients and nephrology professionals is one factor pointing to the urgent need for new, efficient, and effective treatment models. A paradigm shift away from the current model of routine referral of patients for in-center treatment to a new model characterized by early intervention and home-based dialysis therapies is warranted. In the past, a large percentage of patients who required dialysis received treatments at home; in 1973, as many as 40% of dialysis patients in the United States received home HD. The proportion of patients receiving home treatments, however, declined dramatically over the following 3 decades as in-center treatment became the standard of care. By 2004, only about one half of 1% of the Medicare ESRD population received home HD.1U.S. Renal Data System: USRDS 2006 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2006Google Scholar The prevalence of the other home-based therapy, PD, similarly declined from a peak of 14.9% of the Medicare ESRD population in the United States in 1993 to 5.5% in 2004, despite data that indicate that 5-year survival rates after treatment initiation are very similar for PD and HD.1U.S. Renal Data System: USRDS 2006 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2006Google Scholar In younger patients, PD is associated with lower adjusted mortality than in-center HD, independent of diabetic status.3Liem Y.S. Wong J.B. Hunink M.G.M. et al.Comparison of hemodialysis and peritoneal dialysis survival in The Netherlands.Kidney Int. 2007; 71: 153-158Crossref PubMed Scopus (181) Google Scholar, 4Vonesh E.F. Snyder J.J. Foley R.N. et al.The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis.Kidney Int. 2004; 66: 2389-2401Crossref PubMed Scopus (296) Google Scholar Traditional hemodialysis centers are generally unable to provide their patients with the full range of therapeutic options—including home HD and PD—for treatment at earlier stages of kidney disease. Even if available, these home-based therapies are often only offered as poorly supported services secondary to the main activity of in-center hemodialysis. Consequently, home-dialysis programs administered by HD centers often lack sufficient numbers of patients to be efficient and lack enough experienced staff dedicated to the home therapy program. With increasingly more research pointing to the compelling clinical outcomes of home-based therapies, such suboptimal approaches need to be replaced with focused, full-time home-therapy support, integrated with early intervention and effective home-therapy programs. Unfortunately, patients are very often not adequately presented with home-dialysis options before the onset of dialysis. In the 1997 United States Renal Data System Dialysis Morbidity and Mortality Study (Wave 2), only one quarter of in-center HD patients indicated that PD or home HD had been presented to them when initial treatment-modality options were discussed.5U.S. Renal Data System: USRDS 1997 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD1997Google Scholar Our experience demonstrates that when provided comprehensive education about dialysis treatment options, nearly half of patients select a home therapy, with the prospect of fewer fluid and dietary restrictions, more flexible schedules, greater convenience, improved quality of life, and improved health outcomes.6Robar A. Moran J. The effect of education on patient therapy choice: The WellBound experience. Annual Dialysis Conference, Denver, CO2007Google Scholar WellBound was established in 2002, with the aim of improving clinical outcomes and enhancing patients’ quality of life by providing and supporting the full spectrum of self-care home-dialysis therapies. Analyses of critical indicators of patient wellness demonstrate that clinical outcomes associated with self-care that utilizes this model outperform many clinical benchmarks for conventional treatment, including dialysis adequacy, anemia status, nutritional status, hospitalization, and mortality. The model included the expectation that many more patients would choose a home therapy if educated on the possibility and assured of ongoing support. This expectation was certainly fulfilled.6Robar A. Moran J. The effect of education on patient therapy choice: The WellBound experience. Annual Dialysis Conference, Denver, CO2007Google Scholar, 7Moran J. Doss S. Robar A. Results in a large short daily hemodialysis program.Am J Kidney Dis. 2006; 47: A45PubMed Google Scholar Of 986 patients who attended education classes at a WellBound training center between August 2004 and 2006; nearly half (452; 45.8%) chose a home-dialysis modality.6Robar A. Moran J. The effect of education on patient therapy choice: The WellBound experience. Annual Dialysis Conference, Denver, CO2007Google Scholar Of these patients, 79.2% (358) chose PD and 20.8% (94) chose home HD. As of August 31, 2006, a total of 388 patients were receiving home dialysis within the WellBound system; 83.5% of patients received PD treatment (38% CAPD; 62% CCPD); 16.5% of patients received home HD (60 patients with the NxStage System One, 3 patients with the Fresenius 2008K@HOME machine, and 1 patient with the Aksys PHD System). Utilization of CAPD ranged from 13% to 53.5% in the 9 training centers; CCPD ranged from 46.5% to 87%. The differences in PD-modality utilization appear dependent on center care-team preference. Of the 64 home HD patients, 80% (51) performed short-daily dialysis (6 patients every other day, 1 patient 4 days/wk, 6 patients 5 days/wk, and 38 patients 6 days/wk). Twenty percent (13) of the home HD patients performed nocturnal dialysis (2 patients every other night, 1 patient 4 nights/wk, 1 patient 5 nights/wk, and 9 patients 6 nights/wk). Between 2004 and 2006, a total of 98 patients began home HD. The vast majority of these patients (n = 80; 82%) switched from in-center HD to home HD. Only 8 patients (8.2%) were incident patients who chose home HD as their first ESRD modality, 8 patients (8.2%) switched from PD to home HD, and 2 patients (2%) started after failed transplant. The HEMO study failed to show a mortality reduction for patients who received an increased dialysis dose in the context of conventional, thrice-weekly, in-center hemodialysis.8Eknoyan G. Beck G.J. Cheung A.K. et al.Effect of dialysis dose and membrane flux in maintenance hemodialysis.N Engl J Med. 2002; 347: 2010-2019Crossref PubMed Scopus (1638) Google Scholar A logical next step was to consider whether increased dialysis frequency—such as that commonly delivered through home treatment—could improve clinical outcomes. Frequent home HD has been strongly associated with improvements in fluid control, hypertension, and left ventricular hypertrophy in many studies (see recent review by Suri and coworkers9Suri R.S. Nesrallah G.E. Rahul Mainra R. et al.Daily hemodialysis: A systematic review.Clin J Am Soc Nephrol. 2006; 1: 33-42Crossref PubMed Scopus (173) Google Scholar). Likewise, improvements in anemia and a reduction in erythropoietin dose have been reported in many studies that evaluated frequent HD.9Suri R.S. Nesrallah G.E. Rahul Mainra R. et al.Daily hemodialysis: A systematic review.Clin J Am Soc Nephrol. 2006; 1: 33-42Crossref PubMed Scopus (173) Google Scholar Indicators of nutritional status—including serum albumin, serum prealbumin, nPCR, and dry weight/lean body mass—similarly improved in many reports on frequent home dialysis.10Spanner E.D. Lindsay R.M. Nutrition.Contrib Nephrol. 2004; 45: 89-98Crossref Scopus (1) Google Scholar The WellBound experience with short-daily HD shows a major improvement in BP control, with fewer agents and fewer total pills required (Table 1). In contrast, no decrease in the erythropoietin dose to maintain adequate hemoglobin levels was observed (Table 2), and no change occurred in the number of phosphate binders required (Table 3). However, these patients are now eating a liberal diet, with no protein or phosphate restrictions. These findings are in agreement with some, but not all, studies of short-daily HD.11Lindsay R.M. Alhejaili F. Nesrallah G. et al.Calcium and phosphate balance with quotidian hemodialysis.Am J Kidney Dis. 2003; 42: 24-29Abstract Full Text Full Text PDF PubMed Google Scholar, 12Rao M. Muirhead N. Klarenbach S. et al.Management of anemia with quotidian hemodialysis.Am J Kidney Dis. 2003; 42: 18-23Abstract Full Text Full Text PDF PubMed Google Scholar, 13Ting G.O. Kjellstrand C. Freitas T. et al.Long-term study of high-comorbidity ESRD patients converted from conventional to short daily hemodialysis.Am J Kidney Dis. 2003; 42: 1020-1035Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 14Ayus J.C. Mizani M.R. Achinger S.G. et al.Effects of short daily versus conventional hemodialysis on left ventricular hypertrophy and inflammatory markers: A prospective, controlled study.J Am Soc Nephrol. 2005; 16: 2778-2788Crossref PubMed Scopus (242) Google ScholarTable 1Comparison of Blood Pressure Medication UseConventional Thrice-Weekly HDShort-Daily HDP ValueNumber of different medications for BP control1.80.8.00000001Total number of BPm pills2.71.2.000002Differences are highly significant by paired t test. Open table in a new tab Table 2Comparison of Erythropoietin DosesConventional Thrice-Weekly HDShort-Daily HDP ValueEPO dose (U/kg/wk)188.0200.0.5858EPO dose in patients on conventional thrice weekly HD before and after switching to short-daily HD. The difference is not significant by paired t test. Open table in a new tab Table 3Comparison of Phosphate Binder UseConventional Thrice-Weekly HDShort-Daily HDP ValueNumber of phosphate binders (pills/day)8.39.1.2747Number of pills required to control serum phosphate on conventional thrice-weekly HD before and after switching to short-daily HD. The difference is not significant by paired t test. Open table in a new tab Differences are highly significant by paired t test. EPO dose in patients on conventional thrice weekly HD before and after switching to short-daily HD. The difference is not significant by paired t test. Number of pills required to control serum phosphate on conventional thrice-weekly HD before and after switching to short-daily HD. The difference is not significant by paired t test. Similarly, the WellBound results, using standard clinical parameters in PD, show what can be achieved in well-trained and supported patients who are performing a therapy they have actively chosen. The median PD technique survival (including death) is 58 months, and the clinical performance measures consistently exceed those reported by the Centers for Medicare and Medicaid Services (CMS).15Centers for Medicare and Medicaid Services: 2005 Annual Report, End Stage Renal Disease Clinical Performance Measures Project. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Office of Clinical Standards and Quality, Baltimore, Maryland2005Google ScholarTable 4 compares the WellBound results in PD patients for 2006 with the latest available data from CMS.Table 4Comparison of Clinical Performance Measures for PD PatientsWellBound 2006CMS 2005Percent of patients with hemoglobin ≥ 11 g/dL83%82%Percent of patients with serum albumin ≥ 3.5 g/dL72%62%Percent of patients with total Kt/V ≥ 1.792%NAAbbreviation: NA, not available.Results are for all patients for 2006. Data from 15Centers for Medicare and Medicaid Services: 2005 Annual Report, End Stage Renal Disease Clinical Performance Measures Project. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Office of Clinical Standards and Quality, Baltimore, Maryland2005Google Scholar. Open table in a new tab Abbreviation: NA, not available. Results are for all patients for 2006. Data from 15Centers for Medicare and Medicaid Services: 2005 Annual Report, End Stage Renal Disease Clinical Performance Measures Project. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Office of Clinical Standards and Quality, Baltimore, Maryland2005Google Scholar. Numerous studies demonstrate that daily home dialysis can significantly improve the quality of life of people with chronic kidney disease.16Heidenheim A.P. Kooistra M.P. Lindsay R.M. Quality of life.Contrib Nephrol. 2004; 45: 99-105Crossref Scopus (6) Google Scholar Research on frequent home HD indicates that patients report enhanced energy/vitality, improved appetite, fewer sleep disorders, and improved sexual function. Patients on frequent home dialysis reliably tolerate treatment better with fewer intradialytic symptoms than do patients who receive conventional therapy. These improvements in wellness are also associated with increased rates of employment in patients who receive more frequent home dialysis. In addition to significant advantages in clinical outcomes, programs that can offer the full spectrum of self-care, home-dialysis therapies allow the nephrologist and patient the opportunity to tailor the best self-care therapy for the patient’s current health and lifestyle. As the patient’s condition changes over time, the patient may be transitioned smoothly to a new modality of home therapy supported by the program, allowing the patient to continue to experience the clinical benefits and convenience of self-care. Training for home HD generally takes 4 to 6 weeks, significantly longer than that for PD (1 to 2 weeks). This difference is because of the (relative) complexity of the therapy and the need to train the patient or partner on cannulation of the vascular access—an arteriovenous fistula is the preferred form of access, just as for in-center HD. Why do so many patients prefer home HD over conventional in-center treatment? In addition to the clinical advantages of more frequent treatments, many patients prefer home dialysis for its convenience, particularly the flexibility of scheduling treatments. This freedom becomes increasingly important for patients who dialyze more frequently—home treatments eliminate both travel time and time lost to waiting for treatments to begin. Additionally, for those patients who perform daily dialysis at home, the treatments can be performed at the most convenient time, making treatment easier to accommodate in the patient’s daily life. Frequent home HD also eases the dietary and fluid restrictions required with conventional thrice-weekly HD. With some schedules of home therapy (eg, long-nocturnal HD) the requirements for phosphate binders may even be eliminated. Coupled with the clinical advantages, these conveniences of home therapy significantly improve patients’ quality of life. PD is by definition a home therapy, and many patients select it because of its simplicity and because it provides the freedom to travel. In the WellBound experience, incident patients are generally overwhelmed by the relative complexity of home HD, perceived or real. PD provides similar flexibility and autonomy as home HD, and good evidence suggests that patients who begin ESRD treatment with PD and transfer to center HD as appropriate have better long-term outcomes than do patients who are treated solely with in-center HD.3Liem Y.S. Wong J.B. Hunink M.G.M. et al.Comparison of hemodialysis and peritoneal dialysis survival in The Netherlands.Kidney Int. 2007; 71: 153-158Crossref PubMed Scopus (181) Google Scholar, 17Heaf J.G. Lokkegaard H. Madsen M. Initial survival advantage of peritoneal dialysis relative to haemodialysis.Nephrol Dial Transplant. 2002; 17: 112-117Crossref PubMed Scopus (319) Google Scholar Therefore, from all aspects, PD is an excellent initial modality for the patient beginning maintenance dialysis. Effective patient education before the patient’s need for dialysis therapy is at the core of a successful home-dialysis program. Indeed, reaching patients at an early disease stage can play a pivotal role in improving patient outcomes by delaying the progression of kidney disease and the need for dialysis. Effective education and training optimizes selection and delivery of the best-suited, self-care home therapy as the time for dialysis initiation arrives. WellBound currently has 9 free-standing training centers. At these centers, patients receive education on the full-range of ESRD treatment options, either in groups or individually. The education sessions last 2 to 3 hours, are typically led by a training nurse, and include a social worker and dietician. As well as receiving education on therapy options, patients are educated on other important areas, such as nutrition and blood-pressure control. Physicians are encouraged to refer patients with stage 4 CKD for education before the need for dialysis to support patients’ selection of the best-suited home-dialysis modality for their given medical condition and lifestyle, as well as to prepare for initiation of treatment. All treatment options are presented, including conventional center HD, PD (either CAPD or CCPD), kidney transplant, and the various regimens of home HD. For home HD, 3 machines were offered: NxStage System One, the Aksys PHD System, and the Fresenius 2008K@HOME. In our programs, patients’ choice of a home HD system is largely driven by lifestyle, and we have observed no difference in outcomes with these systems. Our patients report that the major reasons for choosing the NxStage System One is its compatibility with traveling and small size. The Aksys PHD System seemed to be chosen by patients who wanted the least burdensome daily dialysis. Unfortunately, this machine is no longer on the market. The NxStage System One is the first portable HD system cleared for home use. It has a simple, compact design and is about the size of an end table. Dialysate is delivered in bags. Thus, this machine eliminates the need for a large water-purification system, as well as the need to receive, store, hang, and dispose of bagged dialysate fluids in the home. With this machine, the dialysis dose is equivalent to the volume of dialysate used; treatment is complete when the prescribed number of dialysate bags are emptied. The NxStage System One is operated with a slow dialysate flow (≤100 mL/min) for most efficient use of dialysate, allowing nearly complete urea saturation. Blood flow is typically set for 400 mL/min or more. A single-use cartridge that includes the dialyzer drops into the cycler and is automatically primed by the machine after the patient spikes the appropriate number of bags. After treatment is completed, the cartridge is discarded and the machine simply wiped down. Recently, the company has introduced a system (PureFlow SL) for producing a 60-L batch of dialysate from tap water; once produced, the dialysate can be used for up to 72 hours. Depending on patient size, this batch is sufficient for 2 or 3 treatments. Patients find this arrangement more convenient than hanging bags for each treatment. For travel, the patient can revert to using bagged dialysate. The Aksys PHD System was designed specifically for short-daily home HD. It is operated by the patient through a touch screen that provides step-by-step, icon-driven instructions, which guide patients through the entire therapy session and simplify training. The Aksys PHD System automatically conducts many of the processes, such as hot-water disinfection of the system, including the lines and dialyzer, and preparation of ultrapure dialysate. The dialyzer and blood tubing set can be reused up to 30 times. Because the extracorporeal circuit stays in place, machine set-up and tear-down time is reduced, as are storage requirements for disposables. As currently designed, the Aksys PHD System requires a long recycle time to generate the next batch of dialysate, so it is not suited for long-nocturnal HD. The Fresenius 2008K@Home machine is built on the same platform as the in-center Fresenius 2008K machine, a reliable, proven system, and requires similar clinical/technical training. It has an ergonomic, short cabinet so that it can be operated from a chair, a more simplified set up than its in-center predecessor, and includes a graphical user interface. A resurgence in the interest in home dialysis is growing in the US in response to proven benefits in clinical outcomes, quality of life, patient preference, cost, and availability of new equipment. In addition, partnership models that simplify program start up and ensure delivery of superior care are now available. When offered complete education about the options in dialysis treatment, a large number of patients choose a home therapy, the majority of whom prefer PD.