When Kirk Kelly switched from in-centre dialysis to home dialysis, he was having trouble. As a working father with two kids, he found it difficult to find 12 hours a week to have his dialysis done. His body was also having a hard time clearing the calcium out of his system, leaving him with calcifications on his hands and feet that were so large he could no longer wear shoes.
He moved to having hemodialysis at home, all night long, and the benefits soon became obvious. “Within six months, I actually played a round of golf and walked the course. My bloodwork improved, my energy levels went up — my wife coined the phrase, ‘Kirk returned to the man he used to be.’”
His dietary restrictions were loosened, and since he was doing dialysis at home and overnight, he could spend more time in his job as a sales manager and with his family and friends. “It was really a revelation,” he says. “I got better physically, I got better mentally, and it fit my lifestyle better.”
Kelly, who is now retired and working as a peer support volunteer for The Kidney Foundation of Canada, was an early adopter of home dialysis. But there’s an increasing push across Canada — and among developed countries in general — towards it.
Many patients prefer home dialysis, it’s much less expensive to the health care system, and medically, it’s just as good. A CADTH report released last week went so far as to say that for all patients who are deemed eligible for home therapies by their care provider, home-based dialysis should be recommended.
That doesn’t mean it’s the right fit for all patients — in fact, most will still need to be treated in hospitals or dialysis centres. “Around a third of people could be treated at home,” says Peter Blake, medical director of the Ontario Renal Network. The U.K.’s National Institute for Health and Care Excellence (NICE) has estimated that 30 percent of patients would be suitable for home dialysis, and Australia’s 2015 rates are around 33 percent — though that ranges widely depending on location. Closer to home, Ontario has seen a similar variation, with home dialysis rates ranging from as high as 42 percent to as low as 14 percent across regions. The provincial average is 26 percent.
Ontario and other provinces are pushing to increase that number and make sure that everyone who could benefit from home dialysis is on it — with varying success.
The benefits of home dialysis
From a medical perspective, home dialysis is just as good as in-centre dialysis. The CADTH review looked at six systematic reviews and 154 studies, and found no difference overall in quality of life between home dialysis and in-centre dialysis. “The evidence suggests they offer similar clinical benefits,” says Gino De Angelis, the clinical research manager who oversaw the report.
Many patients also prefer it. Home dialysis is typically done daily over six to eight hours, often at night, while in-centre dialysis is done three times a week, for four hours at a time. Because it’s slower and more frequent, people often feel better on home dialysis than they do on in-centre dialysis.
It’s also more convenient to do it at home, leaving patients with more time to themselves and freeing them from the costs of commuting. For younger, healthier patients, that might mean the key benefit of being able to continue to go to work. And it gives people back a sense of control, says Blake. “People with end stage kidney failure often report that it shatters them: your time is not your own, you’re on a special diet — it’s a very tough life. … Home therapy empowers those patients.”
But it’s not for everyone. People with limited income may not have suitable living arrangements. And those who are elderly, frail, or have other conditions, like heart disease or cognitive problems, may not be up to doing it themselves. Some of those just need help: About a third of Ontario patients get that from a personal support worker or a home care nurse, which others have informal caregivers. The CADTH review also found that some patients felt home dialysis could be a burden to their caregivers — while others found it much easier on the whole.
HOW DIALYSIS WORKS
Normally, your kidneys clean your blood, combining waste with extra fluid, which you pee out. When people’s kidneys fail — which commonly happens as a result of issues like diabetes — they can have nausea, fatigue, and a build-up of potassium, which causes heart attacks.
Hemodialysis (HD) replaces some of that work with a machine that circulates a person’s blood through it. Waste products are drawn out of the blood into a fluid called dialysate, through a membrane.
Peritoneal dialysis (PD) takes advantage of a natural membrane we have in our abdomen that wraps around our organs and against our abdominal wall, creating a pocket. In PD, dialysate fluid goes into that space and picks up impurities from the blood before being drained out.
The benefits to the system
Another important benefit is cost. Home dialysis costs significantly less than in-centre dialysis, and experts agree that moving more people to home dialysis could represent huge savings in an area that’s among the top costs for provinces.
“Dialysis costs are staggeringly high,” says Paul Komenda, an associate professor of nephrology at the University of Manitoba. Komenda and his colleagues are even floating the idea of consulting with the public about controlling costs by moving to a home-first policy. That would take the in-centre option away from able-bodied people who are capable of doing home dialysis.
“If there was a new cancer drug that offered equivalent efficacy, where one drug you had to come into the hospital for, and one you had to do at home, and there was a difference of [tens of thousands] a year, in most situations you wouldn’t give patients a choice,” he says. “We need to have a frank discussion in this areas with the public. Do we want unbridled choice in this area, or do we want to see this money spent on other things, like screening and prevention programs?”
Other provinces aren’t going that far, but are trying to promote home dialysis by taking a quality-improvement approach. Over the past decade, there has been “a significant philosophical shift towards considering anyone and everyone a potential candidate [for home dialysis],” says Gihad Nesrallah, chief of the nephrology program at Humber River Hospital and an assistant professor at the University of Toronto. Yet there are barriers at every stage, from wait times for inserting catheters to physicians or front-line staff believing that in-centre dialysis is better.
The Ontario Renal Network is supporting home dialysis by promoting access to personal support workers and nurses, ensuring faster access to catheters, and ranking regions against each other on their home dialysis rates. That work has increased the home rates from 23 percent a few years ago to the current 26 percent.
And Alberta just launched a province-wide system called START. It collects detailed data around home therapy usage that’s coded consistently and reviewed to ensure accuracy; uses that data to score programs on detailed steps related to home dialysis; and then helps implement change. “We’re trying to show that if you clean up process, you can move the needle without having to restrict patient choice,” says Rob Quinn, a nephrologist and associate professor in Medicine and Community Health Sciences at the University of Calgary.
But B.C. has been the most successful. After a decade of promoting home-based dialysis, 35 percent of its patients are now on home therapies. Like Ontario and Alberta, B.C. also compares its regions and health authorities against each other, drilling down to issues like having the ability to put in catheters, or not having enough nurses to train patients and caregivers. They also educate people who “crash onto dialysis” after an emergency about their long-term options, in an attempt to avoid what currently happens, when those patients often continue with in-centre dialysis by default.
And they provide standardized educational materials that push the idea of home dialysis as a preferred option to doctors, nurses and patients. “It’s a culture shift, and it has to be among the whole team, as well as the patients,” says Adeera Levin, head of the University of British Columbia’s nephrology division and the B.C. provincial renal agency. “Most people don’t get up in the morning trying not to do the right thing. But if you don’t have the hard data to say that not everybody who could be on home therapies is on them, you don’t change anything.”