Seven Keys to Better Dialysis

In the last couple of years, the academic dialysis literature has finally zeroed in and largely settled on five—of seven—important paths to more inclusive, more patient-focused, and yes, better dialysis:

1. A better way to start dialysis. There is an inarguable logic to so-called incremental dialysis, even though the implementation of it may remain arguable. See my previous posts about a nuanced approach to dialysis start and about potential implementation risks of incremental dialysis.

2. A smarter place to start dialysis. If properly tasked, designed, resourced, and staffed, transitional care units (so-called TCUs) should encourage one-on-one education, assist a less stressful dialysis entry, and enhance interest in home haemodialysis. See my previous post about TCUs.

3. An intelligent suite of equipment: new technology that is more intuitive, smaller, and less confronting. See my previous posts about wearable dialysis and the Quanta SC.

NB: while both are now several years old and could benefit from updating, they remain essentially correct.

It is truly exciting to have new technologies emerging that promise to make dialysis simpler, more accessible, and (hopefully) more environmentally sustainable. (See our green review in Nature Reviews: Nephrology and my environmental editorial in Int J Art Organs).

4. The triumph of water over wastes. We may finally have a long-waited and belated acceptance that the water volume index (UFR) matters more than the waste (solute) index (Kt/V_urea) as a predictor of outcome and patient wellbeing. This key physiological factor is too complex to tease out further here but is dissected in multiple previous KidneyViews posts (too many to list), encapsulated by this “Dialysis 101” explanatory post from April 2019.

5. A recognition that home is best. There is a belated, possibly still grudging, but highly welcomed understanding that home dialysis yields better outcomes at a lower overall expenditure (the latter a bonus, but not the primary objective) and enhanced patient self-esteem as a key beneficiaries.

Why better outcomes? There are two over-arching reasons:

• Home dialysis permits patients to dialyse “at will,” primarily allowing longer, slower, gentler, and more frequent dialysis than that which is delivered by rigid, roster-regimented, time-contracted, brutally fast, and impersonal facility-based dialysis.

• Home dialysis permits flexible self-determined treatment schedules that mix and match within the social structures and lifestyle commitments of patients and families.

In part with this in mind—but also in the knowledge that home dialysis is 25-30% cheaper in all reported cost studies—the White House recently announced an Executive Order: the Advancing American Kidney Health Initiative (AAKHI). This “order” has a laudable aspirational aim—to have 80% of Americans with end-stage renal disease on renal replacement therapies at home by 2025—but with a highly unlikely achievable outcome. See a CJASN editorial by Rajnish Mehrotra and Beth Witten’s blog.

The ‘80% home cohort by 2025’ is to be dually delivered by:

• More home dialysis

• More transplantation

But, the mathematics of this aspirational “order” are flawed, given that:

• Less than 10% of all US dialysis is currently done at home. In Australia it is ~33% and in New Zealand 45%.

• Only a smidge more than 20% (and dwindling) of all dialysis patients are currently on the transplant list due to a complex mix of age, co-morbidity and other “un-transplantable” concerns.

And, two key pillars are still missing:

6. Professional Training. The U.S. will need intensive training and education of nephrologists and dialysis nurses to even dare to hope that the lofty aims of the AAKHI might be achieved. Professional training and the widespread acceptance and adoption of flexible and patient-focused (indeed, patient-demanded) programs remain as the undipped Achilles heels of US dialysis practice.

Dialysis training has not, as best I understand it, been a stand-out feature of nephrology fellowships in many nephrology training programs in the US. Indeed, many trainees can qualify and pass their Nephrology Board exams without any grounding in chronic dialysis at all. (NB: a recent Boards exam was reported to contain a mere 3 questions out of 100 that sought knowledge about dialysis. Moreover, given the recent home initiative announcements of the AAKHI, not one question sought knowledge of home dialysis—neither PD nor home HD. In contrast, in Australia and New Zealand, the training curriculum stipulates that all trainees in the 3-year nephrology training program must minimally demonstrate:

• Management of an adequate number of peritoneal dialysis patients under clinical supervision, in inpatient and outpatient settings, to ensure safe and independent practice. A suggested number of patients is 50. (Page 40)

• Management of an adequate number of haemodialysis patients under clinical supervision, in inpatient and outpatient settings, to ensure safe, independent practice. A suggested number of patients is 50. (Page 41)

• Management of an adequate number of home haemodialysis patients under clinical supervision to ensure safe, independent practice. A suggested number of patients is 10. (Page 43)

To my understanding, no such dialysis training requirements are mandated in US programs, and certainly no training in home dialysis is demanded.

If patients are to be encouraged to dialyze at home (as per the aspirational edict of the AAKHI) then unless there is a wholesale training “blitz” in home dialysis techniques and patient management in current programs that are clearly poorly set up to oversee, then home dialysis will bear the brunt of poor outcomes overseen by poorly trained staff.

Home dialysis—and especially home haemodialysis—is a very different beast than centre-based care. Home dialysis, properly done, requires years of nuanced experience and expertise if optimal outcomes are to be achieved. It is not a matter of simply transposing in-centre regimes into the home.

Practice is different, prescriptions (and I shudder when I apply that word to home dialysis) are different, and above all, professional/patient relationships are vastly different. (Read this post to understand my dislike of “prescription” when attached to dialysis practice.)

Trust must be the paramount ethos in home dialysis but, while trust, transparency, and partnership must/should always trump (pun not intended) everything else, these “commodities of care” are neither common nor high on the prerequisite list of a centre-based dialysis delivery model where dialysis is done to—not done by. Home dialysis demands to be “done by,” but “done to” is the lexicon darling of US dialysis.

To recognise the need for—and especially the ability of—patients to absorb the esteem of self-care would require a quantum change and 180° reversal in the pervasively paternalistic thread of thinking that runs through U.S. medical (and dialysis) care.

I fear that the 5-year aspirational “by 2025” may not be enough.

Importantly, if patients are pushed home without expert training and local—repeat, local—physician and nurse support, simply to help achieve an overly ambitious administrative (and, cynically, a cost containment) goal, only ill can befall them. System-wide failure would then sound the death knell for home care—through no fault of the currently established home models of care.

7. Models of Care. Dialysis done well offers a smorgasbord of options, each tailored as best as possible to the lifestyle aspirations of each individual patient. But, imaginative and optimum care models require a plasticity of thinking, structure, training, and delivery, plus an ability to review, re-set, and re-position if/when things are not working out well. This flexibility is not a current key feature of most in-centre or facility service models. It is certainly not well catered for in models that depend on producing bottom-line profits for shareholders, or company growth at the expense of patient preference.

Dialysis—sadly—has become shoe-horned to fit “our” time, “our” schedules, and “our” convenience. In a care-universe fashioned for “us”—the providers, patients will always come off second best. I blogged recently about the mayhem of modern dialysis, and attempted to show the vast variability of dialysis, and how, in the end, only four things seem to matter:

(1) The lifestyle aspirations of the patient (PD or HD).

(2) The weekly membrane contact time (in HD): a composite of time and frequency that maximises the time allowable for solute and volume removal. The shorter the total, the worse the outcomes.

(3) The inter-dialytic interval (in HD), where the key comparator cut-off ought to be an inter-dialytic gap that never exceeds 43 hours (based on a 5-hour treatment) vs. any option with an interval that does.

(4) The site of delivery: facility (HD) or home (PD or HD).

The desirable (and deliverable) variations in time (t) and frequency (f), the flexibility of regimens, and the malleability of “prescription” that I believe make dialysis good (or as good as it can be) all make a mockery of the rigidity that dominates most dialysis programs.

Adding variable ‘t’ and ‘f’, flexibility and malleability would force a fundamental change in approach that many (if not most) would find a challenge to understand and implement, but implement they must if the models of care are to swing to (or towards) the patient’s favour.

Is American dialysis ready for the AAKHI? I fear not. And, if not, there is much to be done.