- Wayne A. Evancoe, CEO and renal administrator, and Shari Meola, RN, CNN, clinical services coordinator, from Hortense and Louis Rubin Dialysis Center, Inc.
- Dr. John Moran, DaVita vice president of clinical affairs—home therapies
- Brigitte Schiller, MD, chief medical officer, Satellite Healthcare
What are the benefits of more frequent dialysis, and are there any caveats people should be aware of?
Evancoe and Meola: Physiological. More time on dialysis study data has—and is—showing direct benefits of longer, gentler dialysis, especially gentle dialysis, is better. Many physical side-effects or co-morbidities of CKD Stage 5 can be avoided or improved via HHD and PD use.
Economic. Home patients do not have the travel related costs of attending a center three times/week. They also have few or no co-pays by most insurance. Lifestyle. HHD & PD patients have greater diet and fluid flexibility, and can schedule their own treatments during the day or evening to allow more family, work, travel or socializing. Taking control of the disease by self managing can be rewarding for many.
A reality. The HHD patient’s caregiver, spouse or partner can see increased work and stress in assisting. Not always, but both parties must understand the level of work, expectations and commitment needed for a successful HHD life at home in advance. It can become a significant change in the home dynamics.
The clinical view: Liberalization of diet and fluid restrictions is minimal with overnight dialysis, there are almost no restrictions. We often see reduced use of ESAs; BP meds; phosphate binders. No longer does the disease “control” patient and family.
Schiller: Patients undergoing more frequent HD (MFD) mainly at home have been shown to have improved BP, shorter time to recovery after dialysis (less symptoms of feeling “washed out” after dialysis). Significantly better survival has been shown in a cohort of patients undergoing nocturnal HD at home by the Toronto group, where outcome in the nocturnal HD patients was comparable to patients undergoing a cadaver kidney transplant. Retrospective observational studies show that short daily HD both at home and in-center has better survival compared to thrice weekly conventional HD—but these are not randomized data. Sleep disturbance and restless leg syndrome was found to be improved in patients who switched to 6 days per week home HD. Depression was also improved after 4 months. With more frequent HD fluid control can be achieved easier as fluid removal is challenging with the current conventional thrice weekly approach.
Moran: I always start my presentations with showing one of the last articled Belding Scribner published before he died, which asked, “Why do we dialyze three times a week?” Essentially, it’s an accident of history. When Belding Scribner started all this, they were hand making machines, and they found that three days was the minimum they could get away with, and they wanted to get away with the minimum so they could offer it to more people. People say to me, “What’s the evidence that six days is better than three?” and my first reply is “What’s the evidence that three days is better than six? Six days a week, you essentially have to do it all the time. Not many people want to come to the centers six days a week, and not many centers want to dialyze people six days a week. You have to be able to do it yourself. You have to have a home. You have to be trained on how to set up a machine, manage blood pressure and fluid balance. Doing it six days a week gives you the benefit of six days a week. Excellent fluid control, blood pressure control, much better phosphate control. It’s a part-time job. I think the best thing we can offer people is nocturnal dialysis. I think you get better dialysis because you’re getting longer dialysis, and you are also doing it while you’re asleep.
