Welcome to the “Home Hemodialysis Series” on the Renal Fellow Network!
Once Upon a Time
“Perhaps what we need is a home dialysis unit to be placed by the patient’s bedside, so that he can plug himself in for an 8-hour period once or twice a week.”
These are the words from Dr. Charles Kirby’s presidential address for the American Society for Artificial Internal Organs (ASAIO). However, they were not spoken at the turn of the new century to usher in a new era of dialysis, but back in 1961! Home hemodialysis was developed in the early 1960s. The field started originally as an experiment but was later fueled by a case of a 15-year-old girl who at the time was deemed ineligible for dialysis by the Seattle Artificial Kidney Center’s admissions committee.
Many groups (both inside and outside the United States) continued to improve and expand on the modality, and by the mid-1960s, home hemodialysis was recognized as an effective and less expensive alternative to in-center hemodialysis. Not only was it able to cut cost by avoiding the requirement of nursing staff to supervise sessions, but it also afforded a greater opportunity for rehabilitation by allowing for more independence. It turned out such impressive results that by 1972 about 90% of all patients who were on dialysis under the Seattle program were on home hemodialysis.
That Fateful Summer of ‘73
Parallel to innovations in the procedure of dialysis, the social and political mobilization in favor of dialysis as a life-sustaining treatment began in the 1960s. The initial efforts were focused on grants that provided funding for research in dialysis, as well as capital to establish “demonstration centers” to determine the effectiveness of the procedure.
These endeavors eventually led to the “Medicare ESRD program” which provided insurance coverage to patients with end stage kidney disease. Lost in this political landmine was the initial conclusions that favored home dialysis – in 1970, 40% of all the patients on dialysis in the United States were still being treated at home.
In 1972, US Congress passed the Social Security Amendment of 1972 which changed the landscape for the dialysis field. Under these new provisions, Medicare coverage (previously limited to those over the age of 65) was extended to all patients with end stage kidney disease..
Inadvertently, there was a decline in the percentage of patients on home hemodialysis since the application of the program. This was attributed to a change in the patient population that were eligible for dialysis under the Medicare program; older, more medically complicated, and socially restricted patients. There was also a rapid growth in the number of outpatient dialysis units which led to a further reduction in the number of patients on home modalities.
O’ Home Hemo’, Where Art Thou
The rate of decline in home hemodialysis in subsequent years was quite dramatic. Less than 15% of patients on dialysis were on home hemodialysis by 1978, falling to less than 5% by 1980. The prevalence rates of patients on home hemodialysis in the last 20 years have varied from a low of 0.5% in the early 2000s, to the most recent data from the United States Renal Data System (USRDS) showing a rate of 1.8% in 2016.
Is There Hope?
Over the last 10-15 years, there has been a small, but notable increase in the percentage of patients on home hemodialysis, from less than 1% to about 1.8%. This has been attributed to multiple factors; a growing body of research that has shown similar or superior outcomes in patients undergoing home hemodialysis compared to in-center counterparts, the development of dialysis machines that are more patient-friendly and designed specifically for home use (Figure 1), and an expansion by Medicare for incentivizing home modalities.
Overall, things seem to be looking up for home hemodialysis – 1.8% might not seem like a lot of patients, and any further growth is also likely going to be slow. On the other hand, this also means that home hemodialysis is the modality with the largest scope for expansion and improvement.
What’s in Store Next?
There is much excitement in the field , especially with programs such as the Kidney Innovation Accelerator (KidneyX) looking to sponsor $2.6 million for innovations in dialysis treatment in an effort to improve patient outcomes and quality of life.
Among the available modalities of renal replacement therapies, home hemodialysis still remains an untapped modality of renal replacement therapy; we must strive for a future in which home hemodialysis becomes as routine and prevalent as in-center hemodialysis.
We will continue our journey through the field in our new “Home Hemodialysis Series” on the Renal Fellow Network. In our subsequent posts, we will cover the key literature as it pertains to the modality and also have a tutorial on how to write a new home hemodialysis prescription. Stay tuned!
Madhuri Ramakrishnan, MD
Nephrology Fellow, Washington University School of Medicine in St. Louis