Evaluating In-Center Hemodialysis (ICHD) Patients for Home Dialysis

Patient non-adherence to the dialysis schedule or prescribed medication is a common challenge for clinicians serving hemodialysis (HD) patients and has been associated with significant morbidity, mortality and hospitalizations. With in-center hemodialysis (ICHD), also known as “chronic hemodialysis”, some patients may have feelings of powerlessness (loss of control), which can affect their relationship with staff or other patients and result in an individual’s inability to “conform” to the rigid structure required to maintain an ICHD treatment schedule. Considering other modality options, like home hemodialysis (HHD)—or home therapy overall—may provide a degree of control and flexibility of treatment schedules that allow these patients to be therapeutically compliant. This blog post will reference studies, where available, and anecdotal evidence, that highlights the potential for patients with a history of poor adherence to ICHD or psychosocial issues to succeed on peritoneal dialysis (PD) or HHD.

Dialysis centers: Environment and challenges

The patient population receiving dialysis in centers in the United States accounts for approximately 88% of the more than 508,000 total dialysis patients, according to 2016 data published by the United States Renal Data System.

Historically, six categories of factors contributing to non-adherence to ICHD have been identified. These include patient-related, socioeconomic, psychological, therapy-related, pathophysiological-related and health care system-related factors. For many patients, the regime of treating in a dialysis center may be difficult due to any of a variety of personal challenges, such as:

• Need for transportation to and from the facility
• Childcare or family obligations at home that interfere with dialysis treatments
• Financial difficulties that may prevent the patient from going to the center

Additionally, some patients may struggle with the treatment environment or therapy requirements, such as:

• Need to be on a strict schedule to arrive and depart from the facility for three treatments weekly
• Discomfort with noise or routine procedures in the facility
• Perceived lack of privacy during treatments in the facility
• Psychosocial or other personal issues that affect interaction with staff, other patients or the ability to follow diet, medication administration or fluid restrictions–including perceived loss of control over their environment, life, and health resulting from facility-delivered therapy
• Lack of understanding about diet, medication or fluid impacts on their therapy

Any of the above may contribute to what is often called patient non-compliance but is more appropriately termed non-cooperation with the treatment plan or, in certain cases, it may represent an individual patient challenge or concern that was not appropriately addressed with the care team.

Home dialysis: A potential answer to ICHD challenges

Home dialysis, as represented by PD and HHD, is a potential intervention that may assist in addressing the challenges some patients experience with ICHD, listed above. Discussing potential home options during interdisciplinary team rounds when considering treatment options for an apparent non-cooperative patient represents true patient-centered care. Anecdotal evidence, based on our professional experience in home dialysis, suggests that a number of patients who struggled with ICHD treatments may succeed on home dialysis because of the flexibility, greatly reduced need for transportation, greatly reduced fluid restriction and better overall volume control with more frequent dialysis on HHD or daily dialysis on PD.

Regardless of observed apparent “non-compliance” on ICHD, education of the patient on home modalities by the local home dialysis care team (nurse, social worker and dietitian) can be a life-changing first step to improving a patient’s adjustment to end stage kidney disease (ESKD) treatment.

Additional tools, such as the Match-D tool, created by the non-profit Medical Education Institute, Inc., may assist in evaluating patients for home dialysis. The tool is divided into green, yellow and red columns. The red column does not indicate home dialysis is absolutely contraindicated; the patient may instead be able to do home dialysis if certain barriers are addressed and a helper—or partner—is very involved in their care. With support and encouragement, patients with a history of poor adherence to an ICHD prescription may in fact succeed on home dialysis therapy.