Why Use of Home-Based Dialysis Lags

Why Use of Home-Based Dialysis Lags
Delicia Honen Yard
February 23 2009

Despite their advantages, peritoneal dialysis and home hemodialysis remain unpopular modalities

By the end of 2006, approximately 355,000 individuals were undergoing dialysis in the United States. Only 8.2% of them were on peritoneal dialysis (PD). The rest were on hemodialysis (HD), according to a 2008 U.S. Renal Data System (USRDS) report. After a high of 9,407 new patients in 1995, the number of new PD users every year has fallen to 6,725 and accounts for just 6.2% of new dialysis patients—a number that continues to decline from a 1982-1985 peak of 15%, the report noted.

“Fundamentally there's very limited enthusiasm among providers and companies for the use of peritoneal dialysis,” observes Rajnish Mehrotra, MD, associate professor of medicine at the David Geffen School of Medicine, University of California-Los Angeles (UCLA) and associate chief and director for peritoneal dialysis in the division of nephrology and hypertension at Harbor-UCLA Medical Center.

For Dr. Mehrotra, four main issues limit the use of PD:

1. Inadequate training. Most programs are not set up to provide sufficient home-dialysis education to trainees, preventing them from offering such alternatives to dialysis candidates.

2. Concerns about outcomes. PD is perceived to have worse outcomes than HD.

3. Lack of infrastructure. The infrastructure is not in place to provide PD therapy as seamlessly as HD therapy.

4. Financial considerations. The Centers for Medicare & Medicaid Services (CMS) has created incentives for a greater use of home dialysis treatment—for example, waiving the 90-day waiting period for Medicare eligibility for patients who choose PD or home HD (www.homedialysis.org/resources/medicarefaq/). However, some providers are not aware of these incentives. For the most part, in-center HD has been the most lucrative treatment, at least in part because of the profit margin tied to the greater use of injectable medications such as erythropoietin and vitamin D. (Patients who are dialyzed at home do not require as many injectables; they are more likely to have pills than shots.) Also, increases in HD capacity has put more pressure on providers to fill those chairs, as unfilled hemodialysis capacity is quite costly.

Importance of lifestyle

In Dr. Mehrotra's view, virtually all patients with end-stage renal disease (ESRD) are candidates for PD. “I think most physicians don't do much PD because they believe there's a certain candidate who's optimally suited to it, and I couldn't disagree more,” he stated. “The social setup in which an individual lives is a far more important determinant of the best dialysis modality than is the severity of the person's kidney or other co-existing disease.”

According to Dr. Mehrotra, a young, employed, educated individual may appear to be the perfect medical and social candidate for PD, “but if this person hates the idea of doing dialysis at home, he or she would be a disaster at home therapy.”

Conversely, an older, infirm patient who can't get transportation to the dialysis unit and would rather be dialyzed at home may be just fine using the PD cycler.

“There are very few medical conditions that would prevent someone from being able to do PD—for example, having a scarred peritoneal cavity due to multiple surgeries,” Dr. Mehrotra said. “And somebody who is homeless and can't have supplies delivered to them also couldn't do PD. But in the absence of those two circumstances, everything else depends on the patient and the physician.”

Physician bias

A study by Haya R. Rubin, MD, PhD, and colleagues revealed that PD patients rated their care much higher than HD patients (JAMA. 2004;291:697-703). Specifically, 85% of PD patients versus 56% of HD patients considered their care “excellent” based largely on “information given to help choose modality” and “the amount of dialysis information from staff.”

The investigators concluded: “These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.”

“Ideally, the patient should be told about all modalities—all the aspects of hemodialysis, peritoneal dialysis, transplantation, and no treatment,” said nephrologist Susan Bray, MD, clinical associate professor of medicine at Philadelphia's Drexel University College of Medicine and a member of the medical advisory board of the American Association of Kidney Patients. “There is no blanket recommendation for the type of dialysis a patient should undergo at any particular point in treatment. It's a very individual decision, not an across-the-board thing. Unfortunately, generally speaking it's what the particular medical group chooses to do.”

Dr. Bray's opinion is seconded by Marcos Rothstein, MD, a professor of medicine in the division of renal diseases at Washington University School of Medicine and medical director of dialysis services at Barnes-Jewish Hospital, both in St. Louis. “You have places like Hong Kong, where the prevalence rate of PD is as high as 80%, and then you have other countries like Japan, where it's only 3%,” he says. he says. “This tells you that this is society and physician bias more than anything to do with the technique.”

As to possible reasons providers might not present all dialysis options as thoroughly as they should, Dr. Bray observed: “It's probably a lack of time more than anything, or not having a team of nurses and social workers and dietitians to sit and teach the patient. It takes a lot of time to teach patients what the choices are because they are frightened and aren't absorbing everything you're saying. So you really need to have a program for teaching patients what's out there in terms of their dialysis options.”

But the information bottleneck on home-dialysis treatments often can be traced back even further to insufficient education on the provider's end. Nephrology training programs have traditionally emphasized acute care that takes place in the hospital, frequently in the intensive care unit. “Nephrology fellows only see the rejects of PD, the people who fail,” Dr. Rothstein said. “The ones who are doing well don't show up in the hospital.”

“Many nephrology fellows don't have a comfort level with peritoneal dialysis simply because they haven't been exposed to much of it,” Dr. Bray noted.

Anjali Bhatt Saxena, MD, director of PD at the Santa Clara Valley Medical Center in San Jose, Calif., corroborates this assertion by recalling a study in which nephrology fellows were asked how comfortable they were with PD. “Their comfort level was much lower than you would want it to be.”

Dr. Saxena pointed to research showing that more than 40% of patients who undergo intensive education about their dialysis choices would choose PD. “That's a big difference compared to what we see in actuality, where fewer than 10% of patients are on PD, said Dr. Saxena, clinical assistant professor of medicine at Stanford University in California. “Other industrialized countries—for instance, Canada, Denmark, Netherlands, England, New Zealand—have much higher prevalence of peritoneal dialysis.”

Furthermore, she said polls of U.S. nephrologists have revealed that they thought approximately 30% of their patients should be on PD. “That's so different than what we actually have. There's some kind of disconnect.”

Once on HD, always on HD?

Many ESRD patients are automatically started on hemodialysis due to late referral. “They get to us so late in the course of their disease,” Dr. Bray explained. “If a patient has uremia, it takes time to get that treated when you use a gentle treatment like peritoneal dialysis. Patients can't learn how to do dialysis at home when they're uremic; they're just too sick. There needs to be a lot of education done with primary-care doctors to start sending patients to nephrologists at late stage-3 kidney disease, not wait until they need dialysis.”

Once the patient is stable enough to be eligible for treatment other than in-center hemodialysis, they are not necessarily given an opportunity to switch. “Some of these patients don't want to change modalities, but in some cases they're not getting education about their options, including home hemodialysis,” Dr. Saxena related.

This is likely to change now that CMS has enacted its final rule on conditions for coverage for ESRD facilities. According to the regulations, which took effect October 14, 2008, all dialysis patients must have an explanation of all the forms of treatment. If they choose PD or home HD, they must be given information on where they can access such therapy if their current facility doesn't provide it (Federal Register Vol. 73, No. 73, FR Doc. 08-1102; www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp, accessed Jan. 19, 2009).

It is fairly certain that dialysis patients at Barnes-Jewish Hospital will not be left in the dark about their home-treatment choices. “My bias is so loaded toward home dialysis that I offer it to just about everyone,” admitted Dr. Rothstein, who has witnessed the rise and fall of this therapy.

“In 1987, 1988, I had a group of about 35 people doing home dialysis with relatives and paid aids. That went by the wayside because of risk-assessment liabilities. I find that to be tragic, because those patients did better than anyone. At the height we had 20% to 22% of patients on PD. Now we're down to 7%.”

But Dr. Rothstein is not discouraged. “I still offer peritoneal dialysis as a very viable option. The obvious question to ask physicians is what form of dialysis they would do themselves, and at this point I still strongly think that I would go for peritoneal dialysis as my first option, as my entry option.”

That puts a face on the information shared by another home-dialysis proponent, Christopher R. Blagg, MD, FRCP. “In the past few years there have been at least two surveys in which nephrologists were asked which kidney-failure treatment they would get if they weren't eligible for transplant, and the great majority said home dialysis.”

Dr. Blagg is professor emeritus of medicine at the University of Washington in Seattle, executive director emeritus of Northwest Kidney Centers in Seattle, and editor-in-chief of Hemodialysis International, the journal of the International Society of Hemodialysis. His treatment of choice for patients is home HD.

“Home hemodialysis began in 1964 in Seattle, and then Boston and London,” Dr. Blagg recalled. Stanley Shaldon, MD, of London introduced overnight home HD in October 1964, and, as Dr. Blagg noted, “by 1965, we in Seattle were treating patients overnight, three nights a week, with excellent results.”

By Dr. Blagg's estimate, about 10,000 patients were on hemodialysis in the United States in 1972, and approximately 35% to 40% of them were doing the home version. “Programs like ours in Seattle always continued with a significant home hemo program and a peritoneal program, but they faded out nationally during the 1980s and 1990s, for lots of reasons,” Dr. Blagg said. “With almost universal coverage when the Medicare ESRD Program began, the patient population changed, becoming older and sicker, plus the large for-profit corporations were not interested at all in home dialysis in any shape or form for many years. Australia and New Zealand have the highest rates of home hemodialysis in the world, is frequently used, and I think part of the issue is that they don't have for-profit dialysis.”

The 2008 USRDS annual report notes that there were 5,817 individuals on home HD in 1985. Dr. Blagg recalls a steady decline once government studies that paid aides to help these patients folded. By 2002, only 1,756 individuals nationwide were using the treatment.

“Home hemo only accounted for about 0.5% of dialysis patients by the mid-1990s, when doctors in Toronto started doing more frequent nocturnal dialysis, five and six nights a week,” recounted Dr. Blagg, who thinks this is probably the best present-day treatment regimen. “If you dialyze, say, five or six times a week overnight, then instead of getting 12 hours of dialysis a week or less in the in-center hemodialysis unit, you're going to get as many as 48 hours.”

Complementary, not competitive

While some people may view dialysis options as HD versus PD, the real matchup appears to be in-center therapy (hemodialysis) vs. home therapy, both PD and home HD.

“If you look at the literature, I would say nobody really knows whether home hemodialysis or peritoneal dialysis is better,” Dr. Blagg said. “PD is a real good starter. It's not very powerful in terms of the amount of dialysis, but since it's continuous, more or less, you don't have the fluctuations up and down that you get with, say, three-times-a-week dialysis in a center.”

Barnes-Jewish Hospital's Dr. Rothstein, who favors PD, said that although the therapy may have a finite shelf life, physicians still should recommend it and patients should choose it. “Yes, life expectancy on dialysis is seven or eight years, and the technique expectancy for peritoneal dialysis is five to six years,” he argued. “But the problem with saying that PD will end before your life will end is missing the point that peritoneal dialysis is like an extension cord. It extends your renal life; it doesn't use your vascular access. It keeps you at home, in your own environment, before you go into the in-center warehouse. So the fact that you could do four or five good years of peritoneal dialysis and then re-set your thermostat is a great option.”

Peritoneal dialysis can also extend financial resources. The USRDS annual report put the per-patient-year Medicare costs of dialysis in 2006 at $71,889 for HD and $53,327 for PD. For transplants, the figure was $24,951.

Although the report provides no breakout of in-center vs. home HD expenses, Dr. Saxena estimates that PD costs Medicare between $10,000 and $20,000 less per patient per year than home HD. “Even if a patient starts on PD and switches to hemodialysis, there is still a cost savings associated with the time they were on PD.” she said.

Dr. Blagg disagrees, however, noting that the savings are very similar. The big problem for home HD is that payment for this modality “is extremely inadequate,” he said.

Sometimes it's not choice that brings people out of the dialysis centers and into home therapy. Dr. Rothstein related: “I have patients who go kicking and screaming into peritoneal dialysis only after they exhaust their dialysis accesses, and after this Hail Mary pass they say, ‘Why didn't you push me more into this to begin with?' I have to remind them that I did tell them about it, but they were never interested.”

For patients who make a switch in the opposite direction—from PD to HD—Dr. Blagg has some important advice on preparing for this eventuality: “To do hemodialysis you need blood access, which means undergoing surgery to put in a fistula in your arm. I believe very strongly that if somebody starts on peritoneal dialysis, once they're stable and doing well, they should have surgery so that they have an access.”

Dr. Blagg theorizes that because a fistula can take several weeks or even two to three months to mature, having it ready well in advance will enable PD patients to go much more safely and simply to HD.

PD infection risk overstated?

Some mistaken beliefs about PD could partially explain its low usage in the United States. “One of the biggest hurdles peritoneal dialysis has to overcome is its reputation,” Dr. Saxena stated. “Some professionals may not be aware of the improvement in PD outcomes. The infection rate has fallen from more than once a year to once every 40 months or perhaps even more infrequently, thanks to numerous clinical and technological advances.”

She cited studies from the University of Pittsburgh School of Medicine that make her point. One trial, which referred to infection as “the Achilles heel” of PD (J Am Soc Nephrol. 2005;16:539-545), demonstrated the prophylactic effectiveness of gentamicin cream at the exit site. Another study found that very low rates of peritonitis could be achieved through proper care and periodic retraining of patients (Kidney Int Suppl. 2006 Nov; [103]:S44-S54). A third study pointed to the high risk of infection in HD patients (Clin J Am Soc Nephrol. 2006;1:1226-1233).

“Peritonitis is one of the biggest fears for nephrologists and patients, but the actual infection rate in peritoneal dialysis is much less than with hemodialysis, especially hemodialysis using a catheter,” Dr. Saxena said. “Patients who start hemodialysis with a catheter have a very high risk of bacteremia, which is a much more serious infection than peritonitis—but that's not often thought of.”

Home therapy returning?

The availability of more compact, less expensive equipment has contributed to a renewed interest in home HD that drew in 838 new patients in 2005-2006, bringing the number of users in 2006 to 2,455, according to the USRDS annual report. “We have a long way to go to get more people on home hemodialysis, but a change is coming,” Dr. Blagg said. “Home hemodialysis is starting to become acceptable again, and people are using it.”

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