Haemodialysis: hospital or home?

Abstract

Healthcare costs associated with the provision of dialysis therapy are escalating globally as the number of patients developing end-stage renal disease increases. In this setting, there has been heightened interest in the application and potential benefit of home haemodialysis therapies compared with the conventional approach of thrice weekly, incentre treatments. Increasingly, national healthcare systems are financially incentivising the expansion of home haemodialysis programmes with observational studies demonstrating better patient survival, superior control of circulating volume and blood pressure, greater patient satisfaction and lower running costs compared with incentre dialysis. Nonetheless, increasing the prevalence of home haemodialysis is challenged by the technological complexity of conventional dialysis systems, the need for significant adaptations to the home as well as suboptimal clinician and patient education about the feasibility and availability of this modality. In addition, enthusiasm about frequent as well as nocturnal (extended-hours) haemodialysis has been tempered by results from the recent Frequent Haemodialysis Network randomised controlled trials comparing these schedules with a conventional incentre regime. An increasing emphasis on empowering patient choice and promoting self-management of chronic illness is a powerful driver for the expansion of home haemodialysis programmes in the UK and internationally.

Moving Parkinson care to the home

“…Some of that evidence is being gathered currently, 48 and some is being generated in other chronic conditions. 19,52 Preliminary interest in these models for PD is robust. For example, more than 11,000 individuals from 80 countries and all 50 U.S. states visited a recruitment website for a U.S. randomized controlled trial of virtual house calls for PD.…”

Changes in Renal Disease: A Vascular Perspective

“…Performing HD at home requires a complex adaptation to the patients home, often requiring a large team to assess and coordinate therapy; however, in an era when patient autonomy and independence are key priorities, such a therapy can be life changing. 44 Clinically, one particular study was able to show home HD provided an improved patient survival benefit when compared with PD (HR 0.61, 95% CI 0.40-0.93). 45 Not only this, but it is demonstrated that home HD can reduce the cost burden of dialysis on the NHS is reduced, though satellite HD was found to be cheaper than home HD (£1660 and £1490 cheaper at 5 and 10 years), as the effectiveness of home HD meant the cost per quality adjusted life year was superior in home HD.…”

Optimizing Outcomes in the Elderly with End-Stage Renal Disease—Live Long and Prosper

“…Conventional in-center HD (three times weekly 4-hour sessions) in the UK has a survival rate of 79% at 1 year and 47% at 5 years, largely attributable to treatment effects and the burden of multiple co-morbidities (29). Improved patient survival has been associated with increased HD treatment duration with a reported reduction in mortality of 7% for every 30-minute increase in HD session time (30, 31).…”

“…In one study, 10-year survival rates with nocturnal HD were comparable to the 10-year survival of patients who received a deceased donor renal transplant (33). Home HD has also been associated with benefits including better quality of life, decreased recovery time after each dialysis session, decreased antihypertensive drug use and reduced left ventricular hypertrophy (which has been associated with increased risk of sudden death) (29).…”

“…Further potential benefits of home HD for elderly patients include the avoidance of prolonged traveling and waiting times, maintenance of independence and social flexibility and the capacity to provide gentler longer HD sessions without the large hemodynamic variations that can contribute to myocardial stunning and cerebrovascular morbidity (29). Comprehensive training and significant home adjustments are required to facilitate home HD and more typically home HD has been considered for younger highly motivated individuals.…”