A physician and patient perspective on the hope for home dialysis

By Mark E. Neumann. Mr. Neumann has been the executive editor of Nephrology News & Issues since 1989.

If you believe you will not succeed, you won’t. If you think that home dialysis will always have an uphill battle, even as a valued option among modality choices for those with kidney disease, it will be.

It’s looking at the cup as half empty vs. half full, says nephrologist John Agar, and it’s a pessimistic way of looking at the potential for home modalities. Writing in the May issue of Nephrology News & Issues, Agar, a senior nephrologist for the Barwon Health Renal Service in Geelong, Victoria, Australia, said a change in attitude will help advance home choice. “There is an opportunity to empower our dialysis patients—patients we have cocooned in our protective care for so long—as if they are somehow incapable of self-care, of self-determination. Yet, as dialysis physicians and nurses, that is exactly what we say we would choose for ourselves: self-care, self-determination and, being at home.”

If we want it for ourselves, why not for our patients, Agar asks. “In a survey of Scottish nephrologists, 94% would elect home therapy for themselves, with more than 80% choosing hemodialysis over peritoneal dialysis. Yet, similar to the U.S. pattern of home vs. in-center dialysis, 95% of Scottish patients dialyze at a center.”

The opportunity to enable re-engagement—for patient and caregiver alike—with the self-esteem and financial benefits that accrue from a return to work, Agar says, offers awards beyond the benefits of longer duration dialysis. “In addition, let us not forget that dialysis first developed in the United States and around the world as a (largely) home-based therapy,” he wrote.

And what do patients think?

Motivation can make a difference in pressing the home therapy approach forward, but what do patients on in-center dialysis think of the therapy? In a study written by Czajkowski et al. entitled, “Knowledge and perception of home dialysis in ESRD patients: A survey in incident and prevalent patients undergoing in-center HD,” revealed what perceptions patient have about doing home therapies. Of the 316 CHD patients surveyed, the vast majority of both incident and prevalent (> 90 days on dialysis) had been told about home dialysis, with 56–57% having discussed the topic with their nephrologist. But only 30% of incident and 23% of prevalent patients had attended a dialysis options class, and 41% of incident and 52% of prevalent patients voiced a strong preference for in-center dialysis.

The respondents indicated that the main barriers to home therapies were fear of complications and feeling incapable of performing the therapy. Incident patients were more open to a potential switch to a home therapy than prevalent patients, thus suggesting a benefit of early education before or shortly after dialysis initiation, the authors wrote.

If we want to see the glass half full, we need to make a stronger effort in the renal community to provide every patient with the education they need to make a personalized choice.