Dialysis at home makes inroads

Gregory Frison adjusts his dialysis machine at home. "It is pure freedom," he said, compared with treatment at a dialysis center.
Gregory Frison adjusts his dialysis machine at home. "It is pure freedom," he said, compared with treatment at a dialysis center. (MICHAEL BRYANT / Staff Photographer)
Posted: August 25, 2014

Most mornings, Gregory Frison reclines in a chair in the extra bedroom in his Elkins Park home, conversing with his wife, Ann, or a member of his church. And on Thursday nights, he shouts from the same chair during the 76ers games he watches with friends. He never seems to mind the quietly humming dialysis machine next to him, filtering his blood the whole time.

"It is pure freedom," said Frison, who has been dialyzing at home six days a week since March 2012.

Diagnosed with end-stage renal disease seven years ago, Frison started care at a dialysis center before he learned about home dialysis from a nurse. Now the retired teacher, 53, can get more frequent treatments, on his own schedule.

But despite the benefits of home-based care, an overwhelming majority of patients still go to dialysis centers. Patients fear the risks and responsibility that come with this technology. Doctors aren't as willing to prescribe home therapies. And financial barriers still push patients toward center-based care.

Home dialysis has been available for decades, with the first machine introduced in 1964. But with the rise of dialysis clinics and the population aging, this modality fell out of favor, said Ellie Kelepouris, chief of the division of nephrology and hypertension at the Drexel University College of Medicine.

Kidney-failure patients need dialysis to filter waste and toxins from the blood and remove excess fluid.

Peritoneal dialysis, which filters waste from the blood vessels lining the abdomen, is the most common home-based therapy in the United States. But it accounts for only about 6 percent of patients, according to national data.

Home use is even less common for the more traditional hemodialysis, in which an external machine filters the patient's blood. Only 1.4 percent of the 395,656 hemodialysis patients in 2011 were treated at home.

But these numbers don't reflect the data supporting home-based therapies. Normal kidneys continuously filter a person's blood, said Joel Glickman, director of home dialysis programs at the University of Pennsylvania Health System. So the more often a patient dialyzes, the better his or her body functions.

Patients on home hemodialysis can be treated up to six times a week, depending on their doctor's recommendation. And peritoneal dialysis can be done continuously or at night while patients sleep. In-center dialysis is typically done three times a week, every other day.

Home dialysis patients also have better heart health, need fewer drugs, enjoy a better quality of life, and are less likely to die, Kelepouris said.

And for patients like Frison, home therapy frees patients from the clinic where patients come in for shifts at specific times. Frison used to dialyze at Lankenau Medical Center in Wynnewood three times a week for 41/2 hours. Now, at home, Frison can finish in under three hours.

But perceived risks of home therapy prompt many patients to stay in clinics. With hemodialysis, patients' biggest concerns are bleeding out or getting air in their bloodstream, which can be fatal, Kelepouris said.

While these are real risks, home hemodialysis machines have mechanisms that automatically turn them off in the event of dislodged needles or air in the tubing.

There are only two FDA-approved devices for home hemodialysis: Fresenius Medical Care's 2008K@home, and NxStage Medical Inc.'s System One.

Ninety-five percent of home hemodialysis patients use the NxStage System One, said Glickman, who also serves on the company's scientific advisory board. The System One, which Frison uses, is portable, allowing patients to travel with the machine.

Patients are also hesitant about sticking themselves with needles, something a nurse or technician would do in a dialysis center. This was Frison's biggest fear when it came to switching to home dialysis. But now "it's a breeze," he said.

Home hemodialysis also requires extensive training. Nurses train patients for four to six weeks at dialysis centers and then at home, teaching them how set up the machine and handle errors. And each patient must have a trained "care partner" who is present during treatment.

The perfect patient for home therapy is "willing and committed," said Harvey Wells, 62, a former dialysis patient from Euless, Texas, who calls himself a "dialysis evangelist." Wells works for NxStage and travels around in his RV, spreading the word about home hemodialysis.

Still, some patients don't like having the equipment in their homes. "Patients don't want daily reminders that they have kidney disease," said Donna Scannapieco, Fresenius' director of home therapies for the Penndel region.

Doctors may also be contributing to the minimal use of home therapies. Nephrology fellows aren't regularly exposed to home therapies in training, so they are less likely to prescribe it, Glickman said.

But when asked what they would choose for themselves, 91 percent of nephrologists in a 2012 study chose a form of home-based therapy.

"There's a disconnect between what doctors believe and what they do," Glickman said.

This conflict may also be present among dialysis chains, which offer home therapies but still need to fill their chairs, Kelepouris said.

And Medicare doesn't make things easier. Though recent billing changes have incentivized home therapy, especially peritoneal dialysis, centers still run into problems getting home hemodialysis covered for patients. Medicare typically reimburses centers for only three treatments per week, missing the upside of more frequent dialysis.

And some insurers won't even cover home therapies, said Kelepouris, who often has to fight to get her hemodialysis patients covered.

These barriers are worth overcoming, said Glickman, who finds it rewarding when patients see their quality of life improve with home-based therapies. "If someone can do home dialysis, it's a no-brainer."


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