Home haemodialysis

Abstract

Wide variations in availability exist, and the UK lags behind some other countries

Home haemodialysis was pioneered in the United States and United Kingdom in the early 1960s. By 1971, 58.8% of patients on dialysis in the UK and 32.2% in the US received dialysis at home, mostly overnight three times a week. In 2005, these figures were only 2.7% and 0.6%. The poor availability in the UK is in spite of recent guidance from the National Institute for Health and Clinical Excellence (NICE) recommending that “all suitable patients should be offered the choice between home haemodialysis or haemodialysis in a hospital/satellite unit.”¹ Estimates of the proportion of people eligible for home haemodialysis range from about 5% to 20%. In 2006, it was reported that the44 units in the UK that offer home haemodialysis provided it to only 0.6-11.1% of patients; the remaining 21 units had no such programme.² This variation is mirrored in the US—in 2004, 0.2-2.4% of patients on haemodialysis were dialysed at home in 32 states, and no patients were on home haemodialysis in 18 states.³

So, how effective is home haemodialysis and why is its use declining? Home haemodialysis improves survival, quality of life, and the opportunity for rehabilitation compared with haemodialysis delivered to outpatients in a hospital or satellite unit; it is also more cost effective, mostly because of lower staffing costs.⁴ It encourages independence, responsibility, and confidence in patients; it eliminates travel to a unit three times weekly; it is more convenient and comfortable; it allows patients to set their own schedule; and it reduces the risk of infection.⁴Most importantly, it allows more frequent and longer treatment, which further improves quality of life,^{4 5} and seems to reduce mortality and admission to hospital.⁵Short daily sessions of dialysis almost normalise blood pressure, reduce left ventricular mass, and may improve anaemia and phosphate balance. Long nightly sessions of dialysis improve phosphate balance enough to eliminate the need for phosphate binders, and they also increase the clearance of toxic middle molecules (molecules that are larger than urea and creatinine).⁵

Disadvantages of home haemodialysis include the space needed for equipment and supplies, possible plumbing and electrical modifications, increased cost of utility bills, and the need for someone else to be in the home during treatment.⁴

As far as possible, patients should be self sufficient and independent. The importance of involving patients in their own dialysis care was recognised 40 years ago. Recently, the importance of self management of patients in chronic diseases in general has been emphasised.⁶ As a result, the Department of Health developed a national initiative for England, which was based on the concept of the “expert patient.”⁷ However, this initiative does not seem to have been extended to patients on dialysis.

A wide variation in the use of home haemodialysis is also seen in other high income countries. In 2003, New Zealand and Australia had the highest use (58.4 and 39.0 patients per million population), followed by France, Finland, Scotland (8.7), Sweden, Canada, the Netherlands, and England and Wales (6.2); these figures were 4.6 for the US and less than 0.5 for Greece, Iceland, Norway, and Portugal.⁸ Differences cannot be explained by variations in the use of other types of treatment, the prevalence of diabetic nephropathy, healthcare expenditure per capita, or population density. Interestingly, Finland had almost no home haemodialysis in 1998, but since a unit in Helsinki started a programme in 1997,⁹ its use in 2003 was exceeded only by New Zealand, Australia, and France.⁷ This proves that expansion of home haemodialysis is possible.

Reasons for the decline in the use of home haemodialysis include the increasing proportion of sick elderly patients and patients with diabetes who are more likely to have complications; lack of patient education; lack of experience among nephrologists, nurses, social workers, and administrators; and lack of available programmes at many dialysis units.⁴

So what has been the response to this decline? Home haemodialysis and more frequent haemodialysis are beginning to increase in the US. This has been sparked by reports of the benefits of more frequent haemodialysis for patients,⁵ development of equipment that is easier for patients to use, and interest in providing home haemodialysis by the two companies that provide care to around two thirds of all patients on dialysis in the US(Fresenius and DaVita). These two companiesnow have more than 2000 patients on home haemodialysis. Between 2004 and 2005, the number of patients on home haemodialysis in the US increased by 7% and has probably risen by another 20-30% since 2006. The National Institutes of Health is undertaking a randomised controlled trial of more frequent haemodialysis compared with conventional haemodialysis three times a week.

Governments of the Netherlands, Australia, and British Columbia already endorse and support home dialysis and more frequent haemodialysis. In the UK, the 2007 report from the Royal College of Physicians and the Renal Association¹⁰ hardly mentions home haemodialysis apart from a reference to the NICE guideline and a comment about developing services in line with good practice, as described in the national service framework for renal services for England,¹¹ which recommended implementing the NICE guideline on home haemodialysis by 2006. The challenge now is for the UK to reappraise the availability of home haemodialysis in line with the guidelines supporting it and with its uptake elsewhere.¹²