A Systematic Approach To Promoting Home Hemodialysis during End Stage Kidney Disease

Abstract

Home dialysis has garnered much attention since the advent of the Advancing American Kidney Health initiative. For many patients and nephrologists, home dialysis and peritoneal dialysis are synonymous. However, home hemodialysis (HHD) should not be forgotten. Since 2004, HHD has grown more rapidly than other dialytic modalities. The cardinal feature of HHD is customizability of treatment intensity, which can be titrated to address the vexing problems of volume and pressure loading during interdialytic gaps and ultrafiltration intensity during each hemodialysis session. Growing HHD utilization requires commitment to introducing patients to the modality throughout the course of ESKD. In this article, we describe a set of strategies for introducing HHD concepts and equipment. First, patients initiating dialysis may attend a transitional care unit, which offers an educational program about all dialytic modalities during 3-5 weeks of in-facility hemodialysis, possibly using HHD equipment. Second, prevalent patients on hemodialysis may participate in "trial-run" programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training. In both models, perceived barriers to HHD-including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner-can be addressed in a supportive setting. Third, patients on peritoneal dialysis who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (i.e., from peritoneal dialysis to HHD). Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of patients on dialysis. With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of patients on dialysis.

Keywords: cardiovascular disease; chronic; dialysis; education; hemodialysis; home; kidney failure; peritoneal dialysis; renal dialysis; transitional care unit; volume.

Figure 1.

An 8-day continuous hemodynamic trend in a patient who underwent thrice-weekly hemodialysis, according to a cardiac electromechanical sensor device recording. A marked reduction in right ventricular systolic pressure occurred during each dialysis session, followed by progressive pressure increments until the next dialysis session. ePAD, estimated pulmonary arterial diastolic; HD, hemodialysis; RVDP, right ventricular diastolic pressure; RVSP, right ventricular systolic pressure. Reprinted from reference , with permission.

Figure 2.

Schematics of transitional care unit floor plans. These schematics depict a stand-alone transitional care unit (upper left), a home therapies training unit that includes a transitional care unit (upper right), a home therapies training unit that includes both a transitional care unit and in-center hemodialysis stations (lower left), and an in-center hemodialysis floor that includes a transitional care unit (lower right). HD, hemodialysis; HHD, home hemodialysis; PD, peritoneal dialysis; TCU, transitional care unit.