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Educating Patients about Transitioning from In-Center to Home Dialysis

Each year, approximately 100,000 patients face choosing a dialysis modality as they transition from CKD to ESKD. In 2016, 87.3% of incident patients (< 3 months on dialysis) initiated in-center hemodialysis (ICHD) while 9.7% initiated peritoneal dialysis (PD). With the recent Executive Order signed in July 2019 and policymakers promoting underutilized modalities, even more emphasis is being placed on educating patients about preemptive transplant and home dialysis. As a result, a paradigm shift in approaching home dialysis needs to occur for our CKD and ESKD patients.

As providers, we need to continue to present all the options of renal replacement therapies to our patients, including those who have already chosen ICHD or will choose ICHD due to various factors (such as “crash start” onto dialysis, access to pre-dialysis nephrology care, or psychosocial situation), and help them choose the dialysis modality that is right for their lifestyles and their goals. Patient-centered care and shared decision-making is vital to this process.

Not much data is published on the processes around conversions from HD to PD, but here are some current best-demonstrated practices for clinicians and dialysis centers to help facilitate this process.

First, the MATCH-D tool is a standardized third-party resource that may be used to identify patients who are potential PD and home hemodialysis (HHD) candidates. Dialysis facility staff, along with the attending nephrologist and/or medical director, should evaluate every patient in the dialysis facility using the MATCH-D tool to identify any patient who may be a candidate for home therapies. The interdisciplinary team (IDT) can then discuss any potential barriers for that patient before further approaching the patient to ensure patients are having informed discussions on modality choice with their treating nephrologists.

Centers for Medicare & Medicaid Services (CMS) conditions for coverage mandates dialysis facilities and medical directors incorporate an educational program for all dialysis patients regarding modalities as part of the patient care plan. Many observational and retrospective studies show that education for patients increases their likelihood to choose a home therapy. In a randomized control trial, targeted, 2‑phase patient-centered education increased the likelihood of choosing a home therapy compared to routine standard of care in a CKD clinic (82.1% vs. 50%). This type of patient-centered education should also occur in the hemodialysis facility. Patients identified as having a high potential for treating with home dialysis should have further targeted discussions about home therapies, either as part of standardized education that all patients receive or through one-on-one visits with a home modality nurse. This will give the patient and/or caregiver an opportunity to ask specific questions about their lifestyle or home situation that may be a perceived barrier for them to do home dialysis.

Education for the dialysis unit staff can also help dispel myths about home dialysis and help clinical staff feel more comfortable discussing home therapies with their patients. If a facility does not have a home dialysis program, the staff may not be as familiar or as comfortable about discussing home therapies with their patients, and many misconceptions—such as those about PD and diabetes, obesity, pet ownership, parenthood—may be present with the staff. Spending time to educate patient care technicians (PCT), who are first-line clinicians who spend the most time with patients, is important so they can have thoughtful and instructive conversations with their patients about home modalities, including the differences in dialysis therapies and the pros and cons of each type of therapy. Because PCTs work so closely with their patients, these discussions can increase the likelihood that patients will make an informed modality choice.

Identifying an “access manager” (AM) or “home admission specialist” (HAS) in a facility or in a region may help patients considering transition from ICHD to PD through the process. One major barrier for these patients is feeling “lost” in the process from that decision to transition to a home modality to actually training on PD or HHD. ICHD patients generally have complicated medical histories and are in the dialysis facility three times weekly. The AM or HAS can remain accountable for the process by helping arrange surgical appointments for patients, following up post-operatively, setting up the PD catheter flushes if needed, transferring paperwork and setting a training date with the home facility for the patient. Depending on the patient’s needs, the AM or HAS can also help the patient transition to a home modality as safely as possible with backup HD sessions during the training period if needed. The process from modality decision to initiating training is complex for the patient, but having someone help them through that process can make it less intimidating and can result in a smoother transition.

As clinicians, we also need to educate ourselves on transition issues that may arise. For example, patients who transition from ICHD to PD have been shown to have higher mortality, higher rates of technique failure, and higher rates of peritonitis than patients who start with PD first. Patients who transition to PD due to loss of all vascular access and prevalent ICHD who are anuric may confound some of these factors. Data shows that patients with residual kidney function (RKF) have better outcomes on PD than those patients with no RKF. When thinking about ICHD patients transitioning to PD or HHD, we should consider approaching incident patients differently than prevalent patients (> 3 months on dialysis), particularly those patients without RKF. Utilization of backup HD treatments and providing appropriate therapy to meet ultrafiltration goals is necessary for success. Customizing training programs for these patients may also increase the likelihood of a successful transition period from ICHD to a home modality. IDTs should engage early with these patients with coordination of a home dietitian and social worker to have those discussions about the transition period.

By helping patients choose the modality that is right for them, we empower patients to participate in their care, ultimately aiding their likelihood of success on their modality of choice. Teamwork with the patient, ICHD teams, home dialysis teams, attending nephrologists and medical directors is necessary for a successful ICHD to home conversion program.

Mihran Naljayan, MD, FASN, FNKF

Mihran Naljayan, MD, FASN, FNKF

Mihran Naljayan, MD, is a group medical director at DaVita Kidney Care and a practicing nephrologist in New Orleans, LA. He is a graduate of the LSU School of Medicine in Shreveport, LA, and completed his internal medicine residency and nephrology fellowship training at Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School in Boston, MA. Dr. Naljayan is currently an associate professor of medicine at the LSU School of Medicine, Section of Nephrology and Hypertension. He is the medical director of two in-center dialysis units and the LSU peritoneal dialysis (PD) program. His research interests include urgent-start PD, incremental PD and educational curriculum design.