Pub Date: Monday, Aug 15, 2022
Author: Nisha Bansal, MD, MAS
Affiliation: Division of Nephrology, University of Washington
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.
Sarnak MJ, Auguste BL, Brown E, Chang AR, Chertow GM, Hannan M, Herzog CA, Claire Nadeau-Fredette A-C, Tang WHW, Wang AYM, Weiner DE, Chan CT; on behalf of the American Heart Association Council on the Kidney in Cardiovascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Hypertension; and Council on Lifestyle and Cardiometabolic Health. Cardiovascular effects of home dialysis therapies: a scientific statement from the American Heart Association [published online ahead of print August 15, 2022]. Circulation. doi: 10.1161/CIR.0000000000001088
- Foley RN, Parfrey PS and Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1998;32:S112-9.
- https://www.aspe.hhs.gov/sites/default/files/private/aspe-files/262056/advancingamericankidneyhealth.pdf (PDF).
- Flythe JE and Bansal N. The relationship of volume overload and its control to hypertension in hemodialysis patients. Seminars in dialysis. 2019;32:500-506.
- Burton JO, Jefferies HJ, Selby NM and McIntyre CW. Hemodialysis-induced cardiac injury: determinants and associated outcomes. Clinical journal of the American Society of Nephrology : CJASN. 2009;4:914-20.
- Jefferies HJ, Virk B, Schiller B, Moran J and McIntyre CW. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning). Clinical journal of the American Society of Nephrology : CJASN. 2011;6:1326-32.
- Kotanko P, Garg AX, Depner T, Pierratos A, Chan CT, Levin NW, Greene T, Larive B, Beck GJ, Gassman J, Kliger AS and Stokes JB. Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials. Hemodialysis international International Symposium on Home Hemodialysis. 2015;19:386-401.
- Chan CT, Greene T, Chertow GM, Kliger AS, Stokes JB, Beck GJ, Daugirdas JT, Kotanko P, Larive B, Levin NW, Mehta RL, Rocco M, Sanz J, Yang PC and Rajagopalan S. Effects of frequent hemodialysis on ventricular volumes and left ventricular remodeling. Clinical journal of the American Society of Nephrology : CJASN. 2013;8:2106-16.
- Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA and Komenda P. Intensive Hemodialysis and Treatment Complications and Tolerability. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2016;68:S43-s50.
- Chiu YW, Teitelbaum I, Misra M, de Leon EM, Adzize T and Mehrotra R. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clinical journal of the American Society of Nephrology : CJASN. 2009;4:1089-96.
- Copland M, Komenda P, Weinhandl ED, McCullough PA and Morfin JA. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2016;68:S24-s32.
- Daugirdas JT, Chertow GM, Larive B, Pierratos A, Greene T, Ayus JC, Kendrick CA, James SH, Miller BW, Schulman G, Salusky IB and Kliger AS. Effects of frequent hemodialysis on measures of CKD mineral and bone disorder. Journal of the American Society of Nephrology : JASN. 2012;23:727-38.
- Kraus MA, Fluck RJ, Weinhandl ED, Kansal S, Copland M, Komenda P and Finkelstein FO. Intensive Hemodialysis and Health-Related Quality of Life. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2016;68:S33-s42.
- Kraus MA, Kansal S, Copland M, Komenda P, Weinhandl ED, Bakris GL, Chan CT, Fluck RJ and Burkart JM. Intensive Hemodialysis and Potential Risks With Increasing Treatment. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2016;68:S51-s58.
- Chan CT, Collins K, Ditschman EP, Koester-Wiedemann L, Saffer TL, Wallace E and Rocco MV. Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2020;75:926-934.
- Cafazzo JA, Leonard K, Easty AC, Rossos PG and Chan CT. Patient-perceived barriers to the adoption of nocturnal home hemodialysis. Clinical journal of the American Society of Nephrology : CJASN. 2009;4:784-9.
- Shen JI, Chen L, Vangala S, Leng L, Shah A, Saxena AB, Perl J and Norris KC. Socioeconomic Factors and Racial and Ethnic Differences in the Initiation of Home Dialysis. Kidney medicine. 2020;2:105-115.
- Saxena N and Rizk DV. The interdisciplinary team: the whole is larger than the parts. Advances in chronic kidney disease. 2014;21:333-7.
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