Expanding Home Dialysis for Kidney Disease Feasible and Safe

Veronica Hackethal, MD

September 13, 2019

It is feasible and safe to widen the availability of peritoneal dialysis performed at home as initial treatment for patients with advanced chronic renal disease, according to new US research.

In a large-scale program implemented within their integrated healthcare delivery system, Kaiser Permanente Northern California was able to more than double the number of patients with end-stage renal disease starting dialysis using this method over a 10-year period.

Moreover, expanding home dialysis was not associated with increased mortality over time and most patients were still on it 1 year later, according to the results, published online September 9 in JAMA Internal Medicine by Leonid V. Pravoverov, MD, chief of nephrology for Kaiser Permanente's East Bay service area, California, and colleagues.

The findings indicate that peritoneal dialysis provides a convenient and safe way to manage advanced-stage kidney disease compared with center-based hemodialysis, the authors say.

"Peritoneal dialysis remains underutilized nationally. Our study shows that it is possible to greatly expand its use successfully in a large, integrated healthcare system and improve outcomes for patients with chronic kidney disease," senior author Alan S. Go, MD, a research scientist with the Kaiser Permanente Division of Research in Oakland, California, said in a press release.

Indeed, stressed Pravoverov, "Patients who start dialysis at home generally have a better lifestyle, fewer symptoms, and more opportunities to retain employment. The overall quality of life is known to be better for these patients."

Less Than 10% of Americans on Home Dialysis

The number of Americans with chronic kidney disease who may need dialysis is large and growing. Between 2007 and 2014, about 30 million had chronic kidney disease, and in 2016 alone, over 124,000 individuals with end-stage renal disease started dialysis.

In the United States, most patients start with hemodialysis, which entails visiting a clinic several times a week and can take a big toll on quality of life.

In other countries, much higher percentages of patients who begin dialysis for the first time start at home, such as Hong Kong (70%), Mexico (51%), New Zealand (30%), Sweden (21%), and Canada (19%), according to background information in the article.

In contrast, less than 10% of American patients start on home peritoneal dialysis.

There are many reasons for underuse of home peritoneal dialysis in the United States, including lack of financial incentives, inadequate training of healthcare professionals, and fragmented patient care.

But the issue is not without controversy.

Just two companies control 75% of the US market for dialysis. And a recent study showed one of these, DaVita, charges privately insured individuals four times more for dialysis than Medicare patients, as reported by Medscape Medical News.

The vast majority of patients on dialysis — about two thirds — are on Medicare.

And a recently published study showed patients at for-profit hemodialysis units are less likely to be placed on the kidney transplant waitlist than patients at nonprofit units.

Home dialysis is less expensive than hemodialysis, so it would make sense to switch as many patients as possible.

The Trump administration supports a move to home-based dialysis as part of an executive order to improve kidney disease care issued this summer.

And Medicare has recently instituted value-based reimbursement to encourage home peritoneal dialysis as initial therapy. 

How Does Peritoneal Dialysis Affect Outcomes?

Some providers believe that home dialysis worsens outcomes, however.

Although no randomized clinical trial has compared outcomes for home peritoneal dialysis versus hemodialysis, observational studies have suggested similar or even better outcomes with home peritoneal dialysis.

For their initiative, from 2008 to 2018, Kaiser Permanente Northern California implemented a multidisciplinary, system-wide approach to increase use of home peritoneal dialysis that included patient and caregiver education, education, and support tools for healthcare professionals, streamlined system-level processes, monitoring, and continuous quality improvement.

Researchers then retrospectively reviewed adult members of their healthcare delivery system who initiated chronic dialysis therapy from January 1, 2008, through December 31, 2018.

They examined the proportion of patients who started chronic dialysis with peritoneal dialysis versus hemodialysis compared with national trends.

Secondary outcomes included persistence of peritoneal dialysis at 1 year and standardized 1-year mortality rates.

One Third of Patients Using Peritoneal Dialysis as Initial Therapy by Study End

Among 13,500 eligible health plan members in the study (58.1% men; 41.9% women; mean age 64 years), initiation of peritoneal dialysis increased from 15.2% (165 of 1089 all new dialysis patients) in 2008 to 33.8% (486 of 1438) in 2018.

These figures were substantially higher than US national trends (6.1% in 2008 and 9.7% in 2016).

Among people who initiated at-home peritoneal dialysis, 80% of patients remained on it at 1 year, with a significant increase from 2008 (69%) to 2017 (84%).

Mortality rates after 1 year did not change either over the course of the study, at 5.5% to 7.3% (P = .12 for trend) for those starting at-home peritoneal dialysis and 15.5% to 17.3% (P = .89 for trend) for those starting center-based hemodialysis.

"Peritoneal dialysis remains underutilized nationally," Go summarized. "Our study shows that it is possible to greatly expand its use successfully in a large, integrated healthcare system and improve outcomes for patients with chronic kidney disease."

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and Kaiser Permanente Northern California Community Benefit Fund. The authors have reported no relevant financial relationships.

JAMA Intern Med. Published online September 9, 2019. Abstract

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