Anemia, which occurs in over 50% of patients with end-stage kidney disease, should not be considered an obstacle to home dialysis, according to a new report.
Recently enacted US public policy calls for expanding home dialysis for patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), and a new report concludes the initiative holds promise.
The report, published in Kidney International Supplements, states that patients frequently benefit from undergoing dialysis at home instead of medical centers and that anemia, which is common in ESKD, can be managed there.
The Executive Order on Advancing American Kidney Health (AAKH) was issued in July 2019. Among its requirements was a push for home dialysis to provide better care for patients with ESKD and reduce associated costs. Currently, only 2% of US patients on hemodialysis are treated at home, and peritoneal dialysis—a home-based treatment—is infrequently used. The home-based hemodialysis percentages are far below those of other countries, with more than 50% being treated at home in Hong Kong, and more than 25% in Finland and Canada.
Home dialysis comes with several potential advantages, the authors said. Although out-of-pocket costs may be higher, many patients may consider the trade-off worth it in terms of greater schedule flexibility and being better able to hold down a job. In fact, an experiment in Australia found that patients were willing to trade 7 or 15 months of life expectancy to be treated at home because they would not have to travel frequently to in-center visits and would be able to do other traveling. Furthermore, improvements in all-cause mortality, hypertension, left ventricular mass, hospitalizations, and quality of life have been reported by patients undergoing home dialysis.
Anemia, which occurs in over 50% of ESKD patients, should not be considered an obstacle to home dialysis, the authors said. Treatment can be streamlined with the use of the new class of agents called hypoxia-inducible factor prolyl hydroxylase inhibitors. The new drugs can be administered orally at home, in contrast to the current standard of care of IV iron and/or erythropoiesis-stimulating agents.
The COVID-19 pandemic has highlighted the advantages of home dialysis, the authors said, because it reduces the exposure of kidney patients to the deadly disease. Of laboratory-confirmed COVID-19-positive patients reported to the CDC, 71% of those with known CKD were hospitalized. The strain on the health system is exacerbated because 20-40% of COVID-19 patients in the general population develop acute kidney injury and end up needing dialysis.
Home dialysis may not be viable for all ESKD patients, such as older patients with certain comorbidities and cognitive issues, the authors said. However, improvements in technique, including from video-dialysis training, may decrease the odds of infection over time, especially in peritoneal dialysis.
A recent study pointed to concerns over patients undergoing in-center dialysis at the common 3-day-a-week schedule. The treatments were associated with increased arrythmias, mortality, and hospitalizations (P < 0.001 for each). More frequent dialysis (6 times a week vs 3) was associated with better outcomes but came with increased patient burden and costs that might not exist with home treatment. Such studies are not considered definitive, the authors said, because home patients tend to have fewer comorbidities.
The goal of the executive order was to have 80% of dialysis patients either treated at home or receiving a kidney transplant by 2025. Worldwide, ESKD has been increasing, with nearly 6 million patients expected to need either dialysis or transplant by 2030. The prevalence in the US increased by 91% from 2000 to 2017 to nearly 750,000 cases, attributed primarily to longer patient survival.
Another key goal of the executive order was greater awareness of kidney disease. An estimated 9 out of 10 of US adults are estimated to be unaware of having CKD.
Patients with ESKD comprise 1% of the Medicare population but 7.2% of all Medicare claims ($35.9 million), the authors noted. Home-based hemodialysis has been more cost effective over a 5- to 10-year period than in-center treatment.
One key barrier is that only 34% of ESKD patients in the United States were offered the option of peritoneal dialysis and only 12% the option of at-home hemodialysis. “Many US nephrologists may not prescribe home dialysis for their patients with ESKD due to misconceptions and a belief that it may be too burdensome to patients,” the authors wrote.
Rastogi, A, Lerma, EV. Anemia management for home dialysis including the new US public policy initiative. Kidney Int Suppl. 2021;11(1): 59-69. doi:10.1016/j.kisu.2020.12.005