Improving Cardiovascular Outcomes in Patients Treated With Dialysis—Time to Go Home

Shifting paradigms for the treatment of kidney failure
Kidney failure is common and is projected to affect >1.25 million Americans by 2030. It is well established that patients with kidney failure treated with dialysis have rates of cardiovascular mortality 10-20 times higher compared with the general population.¹ Perhaps some of this risk can be mitigated by alternative approaches to dialysis? There is now a movement towards increasing access to home dialysis therapies. The prevalence of use of home dialysis, defined as either home hemodialysis or peritoneal dialysis, is only 13.1% among patients with kidney failure.² The Advancing American Kidney Health Initiative, which was signed by the President of the United States in 2019,³ prioritized access and quality of person-centered treatment for kidney failure, emphasizing use home dialysis therapies. This excellent AHA Scientific Statement “Cardiovascular Effects of Home Dialysis Therapies” highlights the potential cardiovascular benefits of treating kidney failure with either home hemodialysis or peritoneal dialysis compared with in-center hemodialysis, barriers in access to home dialysis therapies, and the importance of building cross-disciplinary partnerships to improve access to and implementation of home dialysis.

Cardiovascular benefits of home dialysis therapies
Home dialysis options include home hemodialysis and peritoneal dialysis, which are both performed more frequently or for longer durations compared with in-center hemodialysis. Both home dialysis options are considered more “physiologic” compared with in-center hemodialysis, which traditionally occurs thrice weekly for 3-5 hours each session. As outlined by this recent Scientific Statement, there are several plausible cardiovascular benefits. One, home hemodialysis and peritoneal dialysis may lead to better blood pressure and volume management through more frequent or longer duration of dialysis. Volume overload is a primary contributor to hypertension and maladaptive cardiac remodeling in patients with kidney failure.⁴ Frequent or longer dialysis allows for more ultrafiltration and at a lower ultrafiltration rate; and decreases the hemodynamic shifts and risks of complications such as intra-dialytic hypotension and myocardial stunning.⁵, ⁶ Studies of more frequent dialysis have demonstrated improvements in blood pressure and left ventricular mass.^7-9 The improvement in these intermediate outcomes may have long-term effects including preservation of ejection fraction and reduction of overall heart failure risk. Also, by improving blood pressure and volume status through dialysis, this may partially liberate patients from blood pressure medications, alleviating the excessive pill burden seen in this population.¹⁰ Second, more frequent dialysis may also lead to improved solute clearance. Accumulation of key solutes, such as phosphate, may be important contributors to calcification, endothelial dysfunction, and cardiomyocyte hypertrophy. More frequent hemodialysis has been shown to improve phosphate control.¹¹, ¹² In addition to the physiologic benefits, better phosphate control achieved through dialysis could free patients from the burden of taking multiple phosphate binders with each meal, thus improving quality of life.¹³ It should be noted that the benefits of home dialysis therapies must also be carefully balanced with possible increased risk of vascular access complications and more rapid loss of residual kidney function among others.¹⁴ Despite the likely favorable risk-benefit profile of home dialysis therapies for some patients with kidney failure, much of the current data is based on only a few studies. Further clinical trials are needed to better determine the intermediate and long-term cardiovascular benefits and safety of home dialysis therapies compared with in-center hemodialysis.

Barriers in access to home dialysis therapies
Despite potential benefits, home dialysis is currently utilized in a select population. There are several patient, provider and system level barriers that may contribute to this unequal uptake of home dialysis.¹⁵, ¹⁶ Patient related medical conditions and preference may present barriers to use of home dialysis therapies. Patient preference may be from the practical aspects (e.g. space at home, physical limitations) as well as the fear or anxiety of performing dialysis at home. Provider level barriers include lack of inadequate training of physicians and other dialysis unit staff. System level barriers include differences in resources at available dialysis centers, which may vary based on local resources and government policies. It should be acknowledged that these barriers have disproportionately affected racial and ethnic minority patients, who are less likely to be treated with home dialysis therapies.¹⁷

A call to action: building more partnerships to increase access to home dialysis
As the authors state, there is a “need to empower wider adoption” of home dialysis therapies. To achieve this goal, interdisciplinary partnerships are needed to counter the fragmented care that many patients with kidney failure experience.¹⁸ Ideally, these partnerships work to deliver person-centered care and education to patients prior to the development of kidney failure, when planning for dialysis ideally occurs. These partnerships may include: physicians across specialties (nephrology, cardiology, vascular surgery, palliative care), advanced practice providers, nurses, social workers, dieticians, pharmacists and many others. Building more cohesive teams can increase access to home dialysis therapies; which may ultimately reduce risk of cardiovascular disease in these patients.

In summary, the time is now to help more patients with kidney failure learn about the option to go “home” for dialysis.