There’s no place Like Home: Overcoming Barriers to Home Dialysis Therapies

Written by Jana Livingston, MSc'24 (Candidate), TMED 801 Student

On March 23rd, the department of medicine had the pleasure of hearing from Dr. Bogdan Momciu, MD, during this week’s Medical Grand Rounds. Dr. Momciu is a nephrologist, assistant professor at Queen’s University and the director of the home dialysis program at Kingston Health Sciences Centres (KHSC). Dr. Momciu’s presentation, titled “There’s no place Like Home: Overcoming Barriers to Home Dialysis Therapies” provided listeners with insight into the various barriers and benefits to home dialysis therapies from multiple perspectives.

Kidney failure or a substantial decrease in kidney function necessitates dialysis treatment, a treatment which functions to remove waste from the blood and maintain homeostasis1. Dialysis treatment falls under two major subtypes, hemodialysis, and peritoneal dialysis (PD)1. Patients can undergo this treatment in a hospital setting, commonly referred to as in-centre treatment or at home, with the latter being the least common treatment setting. In-centre dialysis typically consists of scheduled 3–4-hour sessions three times a week where the nursing staff oversees the entirety of sessions2. Conversely, home hemodialysis (HHD) requires sufficient water supply, plumbing and training but can be completed when desired, including at night while sleeping1. Finally, PD; another form of home dialysis, does not require a stable water supply; however, a small surgery is necessary to insert a catheter into the peritoneal cavity3. Notably, Dr. Momciu highlighted the various advantages to home dialysis from improving patients’ quality of life to long-term survival, supporting the transition for at-home treatment.

As Dr. Momciu described, research has found home dialysis to be more advantageous than the prevailing in-centre treatment setting in various aspects. For instance, frequent home dialysis treatments present lower mortality rates than frequent hospital treatments4. As Dr. Momciu explained, this is likely justified by choice and flexibility of care rather than quality of care. This is because frequent in centre dialysis would be required whereas frequent HHD is self-driven. Furthermore, as it pertains to long-term survival, studies have shown that frequent home dialysis (upwards of 40 hours/week) is comparable to kidney transplants, specifically deceased organ donors, with an adjusted hazard ratio of 0.96 when comparing modalities5. From a cost-effectiveness point of view, when factoring in training and annual maintenance expenses, the various home dialysis modalities were found to be less expensive than in-centre treatment 6. Despite these numerous advantages, Dr. Momciu noted that only 24% of dialysis patients in Canada are undergoing at-home treatment7.

This disparity is best explained by a combination of barriers. From a patient perspective, Dr. Momciu outlined what drives patient decisions. In some instances, patients lack awareness of the various treatment options/settings available to them8. Furthermore, financial and safety concerns including household utility payments and adequate training, respectively, have found to deter patients from choosing home dialysis8. Although home dialysis has found to be advantageous for patients, Dr. Momciu noted that treatment options are not a “one size fits all” and must be geared towards patient goals and priorities. For instance, in contrast to the patient’s family or caregivers, patients are less concerned about mortality but rather criteria that may impact quality of life9. Will I be able to travel? How will this impact my employment? What about my family life? These are all valid concerns at the forefront of decisions surrounding different dialysis modalities10. In most cases, home hemodialysis offers greater flexibility and in-turn a better quality of life for patients10.

This begs the question, what can be done to alleviate these barriers and move towards home dialysis therapies? According to Dr. Momciu, from a medical systems perspective, strengthening patient education early is the key8. Likewise, an individualized approach is optimal and should be considered by physicians. In essence, with increased awareness of the benefits home dialysis offers and confronting existing barriers, the shift from conventional in-centre dialysis to home dialysis is at reach.

Following this thorough and insightful presentation, Dr. Momciu sat down with students of the TMED 801 graduate-level course to continue the discussion surrounding home dialysis therapies. He discussed the difficulties of navigating in-centre dialysis during the pandemic, especially for this vulnerable patient population. Likewise, he highlighted the importance of home dialysis for rural and underprivileged communities who may not have the same level of access to healthcare. On a final note, Dr. Momciu shared with students some career advice as well as a glimpse into his journey becoming a nephrologist.

On behalf of the TMED graduate students, I would like to thank Dr. Momciu for this informative presentation and engaging discussion.

References

1. Vadakedath S, Kandi V. Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure. Curēus (Palo Alto, CA). 2017;9(8):e1603–e1603.

2. Momciu B, Chan CT. Evaluating dialysis adequacy: Origins, evolution, and future directions. Seminars in dialysis. 2020;33(6):468–74.

3. Windpessl M, Prischl FC, Prenner A, Vychytil A. Managing Hospitalized Peritoneal Dialysis Patients: Ten Practical Points for Non-Nephrologists. The American journal of medicine. 2021;134(7):833–9.

4. Tennankore KK, Nadeau-Fredette AC, Matheson K, Chan CT, Trinh E, Perl J. Home versus In-Center Dialysis and Day of the Week Hospitalization: A Cohort Study. Kidney360. 2022;3(1):103–12.

5. Nishio-Lucar AG, Bose S, Lyons G, Awuah KT, Ma JZ, Lockridge RS. Intensive Home Hemodialysis Survival Comparable to Deceased Donor Kidney Transplantation. Kidney international reports. 2020;5(3):296–306.

6. Beaudry A, Ferguson TW, Rigatto C, Tangri N, Dumanski S, Komenda P. Cost of dialysis therapy by modality in Manitoba. Clinical journal of the American Society of Nephrology. 2018;13(8):1197–203.

7. Morfín JA, Yang A, Wang E, Schiller B. Transitional dialysis care units: A new approach to increase home dialysis modality uptake and patient outcomes. Seminars in dialysis. 2018;31(1):82–7.

8. Diebel L, Jafari M, Shah S, Day C, McNaught C, Prasad B. Barriers to Home Hemodialysis Across Saskatchewan, Canada: A Cross-Sectional Survey of In-Center Dialysis Patients. Canadian journal of kidney health and disease. 2020;7:2054358120948293–2054358120948293.

9. Urquhart-Secord R, Craig JC, Hemmelgarn B, Tam-Tham H, Manns B, Howell M, et al. Patient and Caregiver Priorities for Outcomes in Hemodialysis: An International Nominal Group Technique Study. American journal of kidney diseases. 2016;68(3):444–54.

10. Hope J. A patient perspective on the barriers to home dialysis. Journal of renal care. Hope J. (2013).A patient perspective on the barriers to home dialysis. Journal of Renal Care 39(Suppl. 1):3-8. 2013;39(S1):3–8.