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.

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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.