The past, the present, and the future of home dialysis

I am delighted to be the guest editor of this very important issue of Dialysis & Transplantation (D&T) that focuses on home dialysis. It is especially gratifying that some of the most important contributors to the field have agreed to write about the past, present, and future of these treatments for end-stage renal disease (ESRD). With close to 400,000 patients in the United States on dialysis,1 we tend to take these therapies for granted, which is why the article by Dimitrios Oreopoulos, MD, PhD, and Elias Thodis, MD, on the early years of chronic peritoneal dialysis and the article by John Bower, MD, about what it was like to be a true pioneer in offering home hemodialysis—particularly to an indigent population—are so compelling.2, 3 My own involvement with home dialysis dates from 1969 when, while finishing my renal fellowship, I was given the task of starting a home hemodialysis program at Kings County Hospital in Brooklyn, New York—a large city hospital that serves an inner-city population. By 1986, we had 84 patients actively performing home hemodialysis,4 and then for the reasons stated by Dr. Bower, Mitchell Rosner, MD, and Christopher Blagg, MD,3, 5, 6 in their articles in this issue, those numbers declined greatly—not only in our program, but also nationally so that in 2010, fewer than 1% of patients are undergoing hemodialysis at home.7 In 1987, I started a peritoneal dialysis program that has trained approximately 200 patients. Nationally and at SUNY Downstate in Brooklyn, peritoneal dialysis is also decreasing. Following Dr. Bower's article on what home hemodialysis was like in the past, Dr. Rosner gives an elegant review of the exciting new interest in more frequent dialysis, whether it be short daily or long nocturnal. These therapies have sparked a great interest in rejuvenating home hemodialysis, and Dr. Rosner summarizes its reported benefits on cardiovascular disease, mineral metabolism, anemia, quality of life, sleep, hospitalization rates, cost, and survival. He does caution that we must await the prospective NIH frequent dialysis study to see if the early enthusiasm for this is warranted. After briefly reviewing his early experience in Seattle with home hemodialysis, as well as his current interest, Dr. Blagg gives us his thoughts on the future of this important therapy. He is optimistic that it will grow because of the interest of physicians and patients in more frequent dialysis, best performed at home, new machine technology, and perhaps most importantly the fact that Congress, the General Accounting Office, and Medicare and Medicaid have all expressed the view that more treatment should be done at home. At the time of publication, the Final Rules of “bundling payments” for ESRD care are not available and will certainly have an impact. Payment for more frequent dialysis will likely assist growth in this modality. Turning to peritoneal dialysis, Drs. Oreopoulos and Thodis review the very early work in peritoneal dialysis and its evolution through chronic peritoneal dialysis, to continuous ambulatory peritoneal dialysis (CAPD), plastic solution bags, catheters for performing the therapy, and the assault on peritonitis with the “Y” set. They then give the Toronto Western early experience, and growth. For the present state of peritoneal dialysis, Isaac Teitlebaum, MD, tackles the important question of how much peritoneal dialysis is adequate.8 He reviews the current rational for the acceptable level of small solute clearance and reports on the importance of adequate ultrafiltration in patients undergoing this therapy. Tantalizing data on the role of inflammation in adequacy is presented, as well as the role of nutritional status and outcome. Finally, the increasing interest in mineral metabolism and mortality is also presented, although the available data is sparse. Finally, John Burkart, MD, gives us his optimistic view of the future of peritoneal dialysis, citing observational data on the increasing survival of this therapy that rivals that of center hemodialysis for at least the first five years.9 In these times of increasing economic concerns, he presents data on the savings to Medicare and Medicaid that would ensue if more patients were placed on peritoneal dialysis (PD), Dr. Burkart then suggests potential ways of doing this, first by improving the PD education of physicians and nurses, possibly by having regional centers that would have sufficient staff, infrastructure, and knowledge to take care of these patients. He proposes ways in which peritoneal dialysis may dovetail with the interest in “more frequent” dialysis. I think I can best summarize why home dialysis is important by including short stories from two of my patients who dialyze at home. Joey Olivero is a 54-year-old man who was born in Puerto Rico and came to the United States at an early age. He completed two years of college. He became ill with focal segmental glomerulonephritis at age 7 and started dialysis at age 20. At this time, he has been on hemodialysis for 35 years and on home hemodialysis for 26 years. As you will see, he has been employed as a dialysis technician. This is his story in his own words: “I have been fighting kidney disease since a child, age 7. In 1975, my kidneys failed. On October of that year at the age of 20, I started on hemodialysis. In the beginning, I was very sick, weak, depressed, and angry. After about one year, with the help and support of family, friends, dialysis staff, and lots of prayers, my circumstances improved for the better. The dialysis staff recommended that I go on self-care therapy where, with their guidance, I would set up the machine, cannulate myself, and monitor my own treatment. Self-care therapy was good for me. I gained knowledge, skills, and techniques and became a member of my healthcare team. In February 1980, I was hired as a fulltime patient-care tech at a dialysis unit. In 1985, I was promoted to senior tech and in 1986 promoted to assistant chief tech. That same year, I started home dialysis. Home dialysis is not easy nor is it complicated. With proper training and commitment, you can be dialyzing at home. Home dialysis has plenty of advantages. For example, you don't have to go back and forth to the dialysis center, and you can be flexible scheduling your days and times. This was very helpful to me while working. You control your own treatment, you feel better, and you dialyze in the comfort of your own home and your own bed. Another advantage, possibly because of self cannulation, I have had my same fistula for more than 30 years. Whenever I am asked my advice concerning home dialysis, I strongly say, go for it, if you are able and willing to put in the commitment. It has given me a good career as well as a good life. In October 1991, I was blessed to marry my wife and partner.” Anita Brown is a 73-year-old African American woman who was born in the United States, completed one year of college and worked as a teacher's aide before becoming ill with renal disease. She has a history of hypertension, and started in-center hemodialysis in 2000. She is currently undergoing chronic cyclic peritoneal dialysis. Ms. Brown has never had an episode of peritonitis. These are her comments about her therapy: “For the past ten years I have been on a machine. Hemodialysis came first. While on the machine, I experienced cramping of my feet and hands and my blood pressure dropped frequently, resulting in a series of access clotting that, required my arm to be ‘cleaned out’ every so often. After four years of this, I chose to try peritoneal dialysis. Now, for the past six years, it has worked out beautifully for me. There is no cramping and the diet is better. I have more free time at home. I do my therapy every night, beginning at 7:00 P.M. for about 11 hours. I can sleep, read, write, talk on the phone, look at TV, and eat while on the cycler machine. The therapy never leaves me feeling weak. When the treatment is over, I have the desire to sleep. By staying close to the peritoneal dialysis center and my assigned nurse, I think I am doing very well and recommend peritoneal dialysis to anyone contemplating dialysis.”

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