Training Nephrology Fellows in Home Dialysis in the United States

Introduction

Whether various home dialysis options are a better treatment for kidney failure than the almost half-century practice of center-based, thrice-weekly, staff-assisted high-efficiency hemodialysis remains an open question—no randomized trials exist. However, for an individual patient, home dialysis is often a preferred option. The promotion of home dialysis by the Advancing American Kidney Health Initiative (AAKHI) and the financial reward or penalty imparted by the beginning of the first performance year of the mandatory End-Stage Renal Diseases Treatment Choices Model in January 2021 make this question more than a theoretical point of interest (1).

The growth of home dialysis depends on the comfort of the physicians with the modalities, which correlates with education and training (2). Multiple studies report an inconsistent approach to educating nephrology trainees on the practical aspects of home peritoneal dialysis and home hemodialysis during the standard 2-year fellowship (3,4). The lack of a universal, structured home dialysis curriculum, along with inconsistent clinical experience incorporating “small learning” principles, contributes to the lack of consistent competence or at least comfort among graduating nephrology trainees in managing home dialysis therapies (3). We propose a pathway to enhancing home dialysis education during the 2-year training period.

Home Dialysis Rotation

Sufficient clinical experience has no substitute for learning in medicine. As William Osler said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” There are multiple reasons for a less than optimal home dialysis clinical experience: insufficient patient on home dialysis volumes at academic centers; absence of mentors; and heavy, time-consuming inpatient rotations (5). Even when patients on home dialysis are encountered on the inpatient rotations, the experience is skewed as the focus is not on optimal home management. Anecdotally, peritoneal dialysis–associated peritonitis is much of what trainees are exposed to while managing inpatients, creating a negative perception of the modality despite the relative infrequency and dramatic improvement of this complication over the last 2 decades.

We propose a concentrated home dialysis experience during traditional training and a subsequent optional home dialysis fellowship, similar to what has been done in interventional nephrology and kidney transplantation. However, the responsibility for home dialysis rests with the nephrology community. During a home dialysis rotation, trainees would participate in the day-to-day function of the dialysis center, including patient training, continuity clinics, troubleshooting clinical problems, and observing the general function of the clinic. This rotation could be a month or longer, depending on trainees’ clinical interests and the structure of the specific academic training program. On the basis of our anecdotal experience at two institutions, the home dialysis concentration is spread over the academic year or done in approximately 8 weeks consecutively. The programs can collaborate with local nephrologists or adjacent local academic programs for rotations. Along with the dedicated time, fellows could attend continuity clinics for the rest of the year like kidney transplant and CKD clinics, which provide longitudinal care.

Home Dialysis Continuity Clinic

A home dialysis clinic can be offered in the second year as an ambulatory block. Continuity clinics would be structured like CKD or transplant clinics. Fellows would take responsibility for the care of the patient on home dialysis rather than be an observer. Responsibilities include placing orders and medical documentation. Because many of the issues arise at home and are not seen in clinic, a protocol for communication between the nursing staff, trainee, and attending nephrologist will need to be developed.

Home Dialysis Fellowship

The home dialysis fellowship helps develop specialized skills if the trainee aspires to be a home dialysis expert. Nephrology training programs in Canada and Australia offer optional home dialysis fellowships lasting 6 months to 1 year, depending on the trainee’s choice (6). To the best of our knowledge, in the United States, only Mount Sinai in New York and the University of Washington in Seattle offer a comprehensive home dialysis fellowship. We propose that similar fellowship programs should be more readily available, although logistical and financial barriers are obvious. The home dialysis fellows would dedicate time to both the home dialysis outpatient center and the inpatient floors caring for patients on home dialysis. Participation in initial education of patients with CKD, home dialysis initiation and training, and longitudinal care would be substantial.

One of the current barriers in general nephrology training is the incorporation of home dialysis rotations in current clinical rotations. Most academic hospitals' increasing patient complexity and acuity have pressured clinical time devoted to mastering other skills, such as outpatient CKD, outpatient center–based hemodialysis, home dialysis, and outpatient kidney transplantation (5). A secondary barrier remains the funding of an extra year. The funding could be secured from the savings from home dialysis, medical director reimbursement, and joint ventures.

This complexity shows little sign of abating. Part of the answer is that faculty and advanced practice providers may need to share some of the inpatient burdens, allowing the trainee immunity from being “pulled” from outpatient learning to cover the acute inpatient services. Mandating a home dialysis rotation during training, much like kidney transplantation experience, may be necessary. It can be achieved with the cooperation of the Accreditation Council for Graduate Medical Education (ACGME), the American Society of Nephrology, Renal Physician Associates, the National Kidney Foundation, and fellowship program directors.

Home Dialysis Didactic Learning

Several traditional teaching resources, like society conferences, conference precourses, and specialized home dialysis conferences, are conducted nationwide. Many fellows still desire focused home dialysis teaching locally (3). Changing how nephrology faculty members teach will help. Microlearning, defined as any platform that encourages learning in short segments, could be integrated into day-to-day learning even during busy clinical rotations or outpatient clinics. Multiple formats include videos, social media, trivia questions, patient studies, podcasts, journal club, or synopses. Engaging students with the subject matter results in deep learning. For example, easily accessible videos could supplement hands-on experience locally. Even episodes of 3–5 minutes duration could be used during a commute, walking in the hallway, or waiting in line (7). We have developed this type of material in an online program for easy accessibility by the learners and update it frequently.

We initiated a “Home Dialysis Intersession Week” for first-year nephrology fellows at our institution. The fellows spend 1 week observing the daily activities of the home dialysis unit, attending lectures on the basics of home dialysis, and meeting the dialysis interdisciplinary team. This education initiative is well received by the trainees and improves their understanding of home dialysis principles and how a home dialysis center runs.

Ensuring Competence

Most patients on home dialysis are seen monthly in the outpatient clinic, although new regulations even prior to the coronavirus disease 2019 pandemic allowed telehealth visits to account for two of every three monthly physician visits. A nephrology fellow could reasonably experience five to six patients in a monthly half-day clinic. Throughout a fellowship, this equates to about 120 patient encounters in toto. For comparison, this is the exposure obtained in 1 week of rounding on a typical inpatient rotation or 1 month of a typical center-based hemodialysis rotation. Without a measure of accountability, human nature suggests the best-designed program may not be effective. ACGME endorses six domains of core competencies during nephrology training: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (8). Peritoneal dialysis and hemodialysis milestones are described in the maintenance dialysis therapy section, although allying home hemodialysis with other types of hemodialysis (9) (Table 1).

Table 1.

Proposals for home dialysis competence during nephrology fellowship (9)

Home Dialysis Curriculum with Accreditation Council for Graduate Medical Education Core Competencies
Peritoneal Dialysis	Home Hemodialysis
Procedural skills
PD catheter pre- and postinsertion management	Machine setup and basic alarms
PD fluid exchanges	Training sessions
Automated PD cycler setup	Vascular access cannulation
Transfer set exchange
Clinical knowledge and patient care topics
Managing the dialysis prescription (initiation and adjustment)	Managing the dialysis prescription (initiation and adjustment)
Urea kinetics and interpretation	Urea kinetics and interpretation
Peritoneal equilibration test	Home HD water treatment
Volume and BP management	Volume and BP management
CAPD versus CCPD	Buttonhole versus rotating site cannulation of vascular access
Hernia development and treatment	Physical examination and clinical monitoring of vascular access
Peritonitis prevention and treatment	Nocturnal home HD
PD catheter insertion and complications	Calcium mass balance
Exit site care and infection	Potassium mass balance
Alternative PD solutions	Long-term patient management issues
Electrolyte complications
Long-term patient management issues
Administrative skills
Telehealth
Outpatient dialysis clinic management
Home dialysis supply management
Quality assurance program
Economics of home dialysis
Medical directorship training

PD, peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis; CCPD, continuous cyclic peritoneal dialysis.

Future Directions for the Home Dialysis Workforce

AAKHI nudges the nephrology community to analyze current home dialysis education and innovate the current teaching practices. We suggest three proposals: embrace new education technology and techniques, enforce training experience in the accreditation process, and consider a separate home dialysis fellowship. A laboratory or virtual reality simulation could support clinical experience. During ACGME Nephrology Training Program reviews, adequate trainee experience in home dialysis should be considered. Lastly, the separate development of training programs in kidney transplantation and interventional nephrology has been enormously successful. The professional societies, academic programs with expertise, and private practice could geographically create a “center of home dialysis excellence” offering home dialysis education. Such a center could offer experience, mentorship, and didactic teaching for trainees in a region and share those resources and expertise. These centers could help other academic programs develop their own curriculum.

Disclosures

N. Gupta is the Medical Director of DaVita Home Dialysis Unit. N. Gupta reports consultancy agreements for serving on the AstraZeneca Steering Committee; receiving honoraria from AstraZeneca and DaVita; and serving as a member of the American Society of Nephrology Quality Committee and a member of the Medical Review Board of ESRD Network 9. B.W. Miller reports consultancy agreements with Fresenius Medical Services; receiving honoraria from DaVita, Fresenius Renal Therapies Group, Northpointe Meetings, and UpToDate; and serving on the NxStage Medical Scientific Advisory Board.

Funding

None.