Symposium pushes the Home Hemodialysis buttonMark E. Neumann, Executive Editor, Nephrology News & Issues
Dialyzing at home was the only option in the 1960s if you wanted to survive. The bedrooms of households of the lucky few gave birth to a treatment that today helps more than 350,000 individuals.
One of the nephrologists who remembers those days—Christopher Blagg—was the main organizer behind a full-day symposium this past Saturday in Orlando, Fla. that focused on sending more people with renal disease back home. The objectives of the symposium, jointly sponsored by the Annual Dialysis Conference and the International Society for Hemodialysis, were to compare experiences with home hemodialysis in the United States to that of Finland and Australia, discuss strategies to develop or improve home hemodialysis programs, identify resources for HHD patients, and provide updates on ongoing studies and an international registry.
All told, 25 presentations were squeezed into the nearly 10-hour day, and the symposium’s official title, “The Renaissance of Home Hemodialysis: Lessons from the World Over,” aptly represented the discussion and review.
What was the take-home message? Primarily, we need to offer HHD to more patients in the United States. It is an option that needs to be presented—optimally, during the pre-dialysis period—along with peritoneal dialysis, transplant and in-center dialysis. And for some, there is a belief that it remains the best option.
“In the 1960s, when we did dialysis at home, we didn’t call it home dialysis,” said Nancy Spaeth, a Seattle native with a transplant who experienced a number of modalities. “We just called in dialysis.”
Certainly, HHD is not for everyone. The discussions during the day made it clear that home dialysis––whether short daily hemodialysis, nocturnal, standard HD at home three times/week, or PD—requires an individual who understands the rigors of self-care. But others suggested that patients may not need to make HHD a permanent decision. What makes more sense is that it becomes part of a life plan of therapeutic options, as needed. If short daily at home becomes overwhelming, switch to in-center nocturnal, or consider PD. A respite may help ease the workload, but still allow patients to maintain self-care.
The international perspectives at the symposium focused on the value of HHD and patient quality of life. And the good news from these programs in Finland and Australia is they also found cost savings. Ecro Honkanen, and MD from Finland, told the packed audience that the costs of HHD are the lowest among all therapies in his country––if you look long term. Those cost savings for their health care system come from patients who experience improvements in cardiac function, “dramatic” improvement in phosphorus control (particularly in patients who do nocturnal dialysis), reductions in blood pressure, and improved energy levels—which leads, Australian nephrologist John Agar said, to people returning to work in his country.
To get more patients interested in HHD, dialysis staff push a “home first” policy in Finland. Similar to experiences in Australia, patients want flexibility in treatment options.
Not all patients say yes, said Hankinson. There is some reluctance from patients about “hospitalizing” their home. Others show concern about the complicated equipment, self-needling, and the support of a partner. Insomnia is also a problem in about 40% of patients who are on nocturnal, even after three months. But the Finnish nephrologist said the patients dialyzing at home “will not give it up.”
In the United States, home hemodialysis is experiencing a renaissance. Obstacles remain: patients are not always offered the therapy, particularly in rural communities where it makes the most sense. And the issue of reimbursement remains a sticking point. Renal providers need to see Medciare’s willingness to pay for more frequent dialysis as private health care plans now do. The recent push to bundle dialysis payments may not bode well for more expensive therapy like short daily or nocturnal treatments. Will government see the long-term value and pay for “outlier” treatments like home therapy?
Let’s apply the “lessons from the world over” and give home hemodialysis the rebirth it deserves.
For more information on the Annual Dialysis Conference, taking place March 1-4 in Orlando, visit
http://som.missouri.edu/dialysis.
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