A Dialysis Treatment For The Busy Patient

* HEALTH JOURNAL
* OCTOBER 5, 2010

A Dialysis Treatment For The Busy Patient

* By MELINDA BECK

Kidney dialysis is no fun. For most patients, it means sitting in a hospital or clinic hooked up to a machine for three to five hours, three days a week. The schedule is usually fixed, the rooms are typically dreary and many patients leave feeling washed out.

It doesn't have to be that way.

* Melinda Beck reports on how it works and how a Medicare shift may make it easier to receive dialysis at home.

In New York's Staten Island, Francine Hillpot, 55 years old, hooks herself up to a hemodialysis machine in her home for two hours, five days a week. She spends the time working on the computer, watching movies, listening to music or crocheting.

In Seattle, Bill Peckham uses his home dialysis machine overnight, six nights a week. "I'm multitasking while I sleep," says the 47-year-old tradeshow carpenter who took a portable dialysis machine with him white-water rafting in July.

In Great Neck, N.Y., Bonnie Mamiye doesn't need a machine to dialyze. She uses an alternative technique called peritoneal dialysis four times a day, for about 20 minutes. In between, she goes about her day as a high-school tutor and mother of three. "I swim. I hike. I shop. I've done it in hotels, in ski lodges, in Israel and at Disney World," says Mrs. Mamiye, 40.

Besides giving patients more flexibility, home dialysis enables people to keep better control over their blood pressure than if they receive treatment in a hemodialysis center. Because they can dialyze more frequently, like normal kidneys work, patients on home dialysis also are able to follow less restrictive diets and use fewer medications, such as erythropoietin, or EPO, an expensive anemia drug often needed in conjunction with dialysis.
8%

The percentage of the 380,000 U.S. kidney patients who get dialysis at home rather than at a clinic or hospital.

Studies show that patients are less likely to be depressed when they dialyze at home. And home dialysis is significantly cheaper than being treated in a clinic or hospital.

Yet of the 380,000 Americans on dialysis, only about 1% of patients used home hemodialysis in 2008, and just 7% used peritoneal dialysis, according to new figures released last week by the U.S. Renal Data System. In other words, "Ninety-two percent of people are getting the worst possible dialysis care at the highest cost," says Dori Schatell, executive director of the Medical Education Institute, which operates Home Dialysis Central, an educational website funded in part by dialysis centers and equipment manufacturers.

Some health experts say many kidney doctors don't encourage patients to explore home dialysis options. "The easy thing to do is stick a patient in the kidney unit," says John Bower, former chief of nephrology at the University of Mississippi Medical Center. "It requires a lot less time on the part of the physician and the dialysis team than educating them about home dialysis," he says.

Dialysis is the process of pumping a patient's blood through a filtering machine and returning it to the body. People need dialysis when their own kidneys no longer function sufficiently to regulate their body fluids and remove toxins from the blood. Kidney disease, which if left untreated can be fatal, is often a consequence of diabetes or hypertension as well as specific kidney problems. A transplant is usually the best option, but the shortage of donor kidneys makes that difficult. Currently, some 77,000 Americans are waiting for a kidney transplant.

The symptoms of kidney disease can be subtle—including trouble concentrating, lack of energy, nausea and poor appetite—so many people don't know they have a problem until they are in renal failure. At that point, they may need to begin dialysis immediately, which leaves little time to consider options or learn to do complex procedures at home.

Many patients simply prefer to have their dialysis done at a center. "A lot of them are scared, and they're pleased to have someone take care of it for them," says Joyce Jackson, president and chief executive officer of Northwest Kidney Centers in Seattle, which serves 1,300 dialysis patients, including 175 that it supports with dialysis at home. Dialyzing at a center also lets patients socialize and not feel isolated.

Medicare, which covers patients of all ages with advanced kidney disease, has also subtly favored in-center dialysis over the years, but that's about to change. Starting in January, new Medicare rules will give dialysis centers a financial incentive to keeps costs down, since centers will reimbursed in "bundled" payments per treatment, rather than billing separately for items like medications. Medicare will also increase reimbursement for training on home dialysis and compensate health-care providers for up to six sessions to educate patients about all treatment options.

"Everybody is looking at the most cost-effective form of care, and home dialysis really rises to the top," says Ms. Jackson.

Even when patients do their own treatments at home, they need a center for training and standby assistance. Only about half of the nation's 5,000 dialysis centers currently offer home treatments. Centers also typically require patients to have a trained helper with them during treatments to help set up and to handle emergencies.

Medicare will also increase reimbursement for training on home dialysis and compensate health-care providers for up to six sessions to educate patients about all treatment options.

"Many patients are candidates for all four treatments; ideally, they should be offered them all," says Joseph Vassalotti, chief medical officer for the National Kidney Foundation. He also notes that about 10% of patients with chronic kidney disease get "pre-emptive" transplants, without ever going on dialysis, an option experts think could be utilized more if more patients and potential donors knew more about it.

Some experts worry that getting dialysis at a center makes patients more complacent about their treatment, and less careful with their health. Home dialysis, on the other hand, demands that patients be active participants in their treatment—from ordering their own supplies and keeping logs of their weight, blood pressure and fluid output to inserting needles in their own arms.

"You definitely have to be a take-charge kind of person," says Mrs. Hillpot, who starts her home dialysis treatments by scratching open the tiny scars that have formed in her forearm, where a surgically implanted fistula joins an artery and a vein under her skin. She inserts two needles: One draws blood out of her body, through thin tubing and into the dialyzing machine, and the other returns the cleaned blood back into her body. During the treatment, she needs to monitor her blood pressure, pulse and the machine's pumping speed. Before dialyzing, she needs to mix the dialyzing solution and sterilize the equipment.
Where to Ask

For more information on home dialysis, contact:

* Home Dialysis Central
* The National Kidney Foundation
* American Association of Kidney Patients
* National Kidney Disease Education Program

Her husband and two friends take turns assisting in the procedures. "I couldn't do it without them," she says.

A big advantage to home dialysis is that patients can do shorter treatments more frequently than the thrice weekly sessions typically offered in centers, which makes each less physically draining and allows less fluid and toxins to build up in between. Longer, slower, treatments overnight offer the same advantage.

"I'm healthier and happier doing it at home," says Mrs. Hillpot.

Medicare pays for the cost of equipment and supplies, but home hemodialysis patients may need to make home-plumbing alterations and incur higher water and electric bills. "It's like hooking up a washing machine—you need a water line, a water drain and a 30-amp circuit," says Dr. Bower.

Peritoneal dialysis requires less equipment and doesn't involve blood or needles, but still takes considerable care and effort. Patients have a catheter permanently implanted in their abdomen. Those on "continuous ambulatory peritoneal dialysis," like Mrs. Mamiye, typically infuse about two liters of a dextrose solution into the catheter four times a day. The fluid "dwells" in the area around the intestines for about five hours at a time, drawing toxins and excess water from the bloodstream through tiny capillaries in the abdominal lining. At each "exchange" session, which takes about 20 minutes, the patient drains out the toxin-filled water and replaces it with new fluid.

"My body is sort of being fooled into thinking my kidneys are working all the time," says Mrs. Mamiye, who does her exchanges at 7 a.m., and again at 1 p.m., 7 p.m. and around 10 p.m. But that schedule is flexible if she has other commitments during the day.

Another form of peritoneal dialysis uses a machine that controls the exchange cycles automatically overnight while patients sleep.

Patients on peritoneal dialysis can't be morbidly obese or have had many abdominal surgeries, and they must take care to avoid infection in the catheter. "If you keep your hands clean and your house clean and do things the way the nurses teach you, you'll be fine," says Mrs. Mamiye.

Write to Melinda Beck at HealthJournal@wsj.com

http://online.wsj.com/article/SB10001424052748704847104575531894007324242.html