United States Lags Behind Other Countries in Home Dialysis

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MARCH 17, 2020 -- The push for home dialysis in the United States is taking on a new urgency in the backdrop of COVID-19, according to nephrologist Christopher Chan, MD, head of the division of nephrology at University Health Network (UHN) in Toronto.

The first two patients in the United States known to have died from COVID-19 were outpatients at dialysis centers in the Seattle area.

"In the context of a pandemic, home dialysis makes even more sense," he told Medscape Medical News. "End-stage kidney disease patients are relatively immunocompromised, and the current practice of in-center dialysis does not allow for social distancing. Home dialysis can provide life-sustaining therapy while minimizing exposure."

Increasing the number of Americans on home dialysis is already on the radar, especially because the Advancing American Kidney Health initiative — launched last year by President Trump — aims to have 80% of new patients with end-stage renal disease (ESRD) on home dialysis or receiving a transplant by 2025, Chan explained.

The 80% goal is "aspirational," Chan said, but added that he hopes the plan will jump-start change. Two other goals are to double the number of kidneys available for transplant and reduce ESRD numbers by 25%, both by 2030.

This might help "direct nephrology in the US to get prepared and educate, and also put together the infrastructure to train patients to undergo these types of complex medical tasks," said Chan, who was scheduled to speak at the International Society of Nephrology: 2020 World Congress of in Abu Dhabi, United Arab Emirates. The conference, which was to run from March 26 to 29, was one of many canceled in response to the COVID-19 pandemic.

Current Rates of Home Dialysis

The current rate of home dialysis in the United States is close to 10.0%, up from 6.1% in 2008 and 8.3% in 2016, according to the US Renal Data System.

"Most countries that currently have a pro-home-dialysis position tend to have around 30% to 40%," said Chan. "That's with a significant amount of education, at the trainee level all the way up to practicing nephrologists. Those have taken a lot of time to build."

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A lack of comprehensive education for patients and providers on the benefits of home dialysis is a barrier to uptake in the United States and in other countries.

In Toronto, multidisciplinary teams of nurse educators, pharmacists, social workers, and nephrologists work to educate patients about dialysis and manage their educational needs, he reported.

"If someone is prepared and taught about home dialysis, they are much more likely to start," said Chan. Education and support can help patients overcome a fear of needles and any discomfort they feel at being without medical staff and separated socially, he and colleagues write in their 2019 report.

But that level of multidisciplinary management and education is not available in many parts of the world. And, said Chan, "doctors, nurses, and the entire team need to understand the messaging and the clinical benefits."

Only 13% of 154 countries offering dialysis and transplant services — all high-income countries — had home hemodialysis options, a 2019 survey showed.

Use patterns for home dialysis differ by country. In Canada, a significant number of patients opt for nocturnal hemodialysis, whereas in the United States, patients tend to go for shorter daily hemodialysis sessions, Chan told Medscape Medical News. In Australia, hemodialysis every other night is the most common regimen.

Home dialysis won't be a solution for everyone because some patients won't be able to manage the process for medical, social, or economic reasons. "However, for the majority of suitable patients, we would certainly advocate for them to consider home therapies," he said.

Coordination Lacking Between Hospitals and Centers

Poor care coordination between hospitals and dialysis centers and a lack of communication are standing in the way of lower hospitalization and readmission rates, said Laura Plantinga, PhD, assistant professor of medicine at Emory University School of Medicine in Atlanta, who was scheduled to speak on dialysis trends in patients with ESRD at the conference.

Readmission rates have been fairly consistent in recent years for patients with ESRD, and currently "about a third of hospitalizations result in readmissions in this population," she told Medscape Medical News.

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But when patients with ESRD are admitted to the hospital, the dialysis center often doesn’t know until they miss an appointment, she explained. And delays in hospital discharge summaries mean that physicians are having to make phone calls to track down patients.

Weight loss during a hospitalization is also an issue because it can necessitate a change in dialysis prescription. "Some of the readmissions we see are fluid overloads because dialysis centers didn't change the weight of the patient," Plantinga said.

A common complaint on both sides is the lack of communication about a patient's medications, especially antibiotics, she added.

This lack of coordination can have economic consequences.

Hospital readmission at 30 days is a clinical measure used by the Centers for Medicare & Medicaid Services ESRD Quality Incentive Program. Hospitals have been fined for high readmission rates since 2013; in 2017, dialysis centers began to be penalized as well.

It's too early to tell whether readmission penalties for dialysis centers are helping to bring down the numbers, Plantinga reported.

Her team at Emory is testing a web-based program, called DialysisConnect, to share real-time information between hospitals and dialysis centers — where the patient is receiving treatment, dialysis schedules, body weight, and complete medication lists — to overcome the fact that different facilities use different electronic health record systems.

"We're trying to find the most critical information to go back and forth," she said.

Guidance for the management of patients on renal dialysis who have COVID-19 was updated last week by the Centers for Disease Control and Prevention, as reported by Medscape Medical News.

International Society of Nephrology (ISN): 2020 World Congress.

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