By Eftyhia Helis

One of the most vivid memories of my teenage years is that of my dad, in his late 30s at the time, leaving the house early in the morning to go to a hospital in a bigger city 100 kilometers from our hometown for his dialysis treatment.  I will never forget  the agony our family felt on “dialysis days” as he was heading out in the morning or the relief when he was finally back home late in the evening – a routine we repeated three days each week. But our story is not unique and probably sounds familiar to many people with end stage kidney disease (ESKD); especially those who do not have access to a dialysis facility in their area.

Our kidneys are responsible for filtering our blood to remove excess fluid, salt and waste products from our body as urine. Kidneys also play a role in regulating blood pressure and the levels of certain minerals in the body. Kidney disease often shows no symptoms for a long time until the disease has progressed to a point where kidney function is quite low.  ESKD is the final stage of the disease progression when kidneys can no longer filter enough waste out of the blood to meet the body’s daily needs. Treatment options focus on replacing the kidneys’ function and include dialysis or kidney transplantation. Unless a patient receives a kidney transplant, life-long dialysis is usually required.

According to data from the Canadian Institute for Health Information (CIHI), over 35,000 Canadians were living with ESKD in 2015. Approximately 60 per cent of these patients were on dialysis.

Hemodialysis (HD) and peritoneal dialysis (PD) are the two main types of dialysis provided by Canadian kidney care programs. In HD, the patient’s blood is circulated through an external dialysis machine that filters the blood before returning it to the body. HD can be done in a clinical setting (i.e. hospital, community dialysis unit) with the assistance of a medical professional, but it can also be done at home by the patient and/or a trained caregiver without professional assistance (self-care HD). Several options for HD delivery frequency are available (ranging from two to nine hours per session) and treatment must be repeated several times a week.

PD requires a permanent catheter in the abdomen. During treatment, a cleansing solution (dialysate) is circulated through the catheter inside part of the abdominal cavity to absorb waste and fluid from the blood.  In this process, the peritoneum (abdominal lining) acts as a filter and waste and extra fluid are discarded from the body. PD is usually done at home (can also be done at work or while traveling), and can be performed while the patient is asleep or awake and with assistance or without (self-care).

Given the life-long aspect of dialysis treatment, home-based options may allow for greater flexibility in eligible patients’ daily lives. In 2009, the Globe and Mail featured an article with the title: “At-home dialysis touted as the next best thing”. However, currently in Canada, most patients needing dialysis are treated with HD offered in a clinical setting with the assistance of health care professional. Should home-based options be considered more frequently for eligible patients? Is this feasible? How would an increased uptake of home-based dialysis affect patients’ quality of life and the health care system?

CADTH, an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures, conducted an evidence review on different options for dialysis, including home-based HD and PD. The review did not find differences in clinical benefits, such as quality of life or survival, between patients who are treated with HD in a clinical setting and those who are treated with HD or PD at home.  It was noted, however, that younger patients on home HD and PD may have better survival outcomes compared with elderly patients. From an economic perspective, the review also concluded that home-based therapies are less costly than in-centre dialysis for the health care system, however, some costs associated with home-based treatment (e.g. cost of water and electrical power needed for home HD) may be significant for patients. If such expenses are not covered by health care plans, the financial burden for patients choosing this type of treatment is an important consideration.

CADTH also identified evidence showing that patients value treatment conditions that are the least disruptive to their daily activities and their caregivers’ lives.  This means that home-based dialysis would work better with some patients’ lifestyle while for other patients the preferred choice would be in-centre treatment. While patients trust their doctors to help them make a treatment decision, they also report that having information about all treatment options (e.g. what to expect, impact on quality of life) and being involved in their dialysis decisions helps them feel more comfortable with their treatment. Another important component of the decision-making is sharing information with the patients’ caregivers;  caregivers play a significant role in supporting patients’ treatment and are also affected by the choice of dialysis modality, in-centre or home-based.

Home-based dialysis can be particularly useful for patients living in rural or remote areas with limited access to urban centres. Often, these patients, and in some instances their families as well, have to relocate to be closer to treatment facilities. While several infrastructure conditions must be satisfied for having dialysis at home (e.g. space and storage for treatment supplies, transportation access for supply delivery, reliable water supply and electricity), at home treatment is feasible in these areas. Comprehensive training (for patients, caregivers and nursing support staff), well-established procedures addressing challenges specific to care in rural or remote settings, and the use of technology (i.e. teledialysis) may facilitate the successful implementation of home-based dialysis, eliminating the need for these patients to move to urban centres for treatment.

In summary, according to available evidence, for eligible patients (as assessed by their health care provider), home-based dialysis could be considered as a first choice for treatment. However, implementation factors, including the local kidney care environment and infrastructure, as well as patient preference, and education about dialysis options need to be addressed in the treatment decision-making process. In some parts of Canada, significant work to support home-based dialysis is taking place. Sharing this information and connecting health care professionals and patients with these experiences is important.

To learn more, visit www.cadth.ca/dialysis or speak to a CADTH liaison officer in your region.

Eftyhia Helis, MSc, is a Knowledge Mobilization Officer at CADTH.