Top Things to Know: CV Effects of Home Dialysis Therapies
Published: August 15, 2022
Prepared by Mark Sarnak, MD
- Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease.
- Currently, intermittent thrice weekly, short-duration in-center hemodialysis is the most common therapy worldwide for patients with treated kidney failure; however, the outcomes with this regimen are poor.
- Emerging evidence supports the overarching hypothesis that administering home dialysis therapies, including home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and outcomes when compared with intermittent thrice weekly short duration in-center hemodialysis.
- Enhanced solute clearance coupled with a more physiological approach to volume removal with more frequent or longer home hemodialysis, results in improved control of blood pressure, improved control of parameters associated with bone and mineral metabolism, reductions in ventricular volumes and regression of left ventricular mass.
- Peritoneal-based therapies provide an alternative to bloodstream-based ultrafiltration in individuals with ascites, left ventricular assist devices, pulmonary hypertension, and aortic stenosis as well as other cardiac devices, particularly pacing leads, where hemodialysis access can lead to life-threatening and device-threatening infections.
- Peritoneal dialysis, particularly when there is residual kidney function, is an attractive mode of dialysis therapy for patients with cardiovascular disease as it provides greater hemodynamic stability in contrast to thrice weekly hemodialysis.
- The Advancing American Kidney Health Initiative, established from a 2019 United States Presidential Executive Order, set goals to support kidney health and treatment of kidney disease. This includes a focus on increased utilization of home dialysis and is aligned with the American Heart Association’s 2024 goal of supporting health equity by identifying and removing barriers to health care access and increasing healthy life expectancy.
- With the AHA’s focus on every person deserving the opportunity for a full, healthy life, it is imperative to consider health equity when evaluating access to home therapies for kidney failure.
- Given the enhanced focus on shared decision making to achieve goal-directed, person-centered care that is accessible to all individuals, this manuscript suggest an interdisciplinary care model to support optimizing cardiovascular outcomes for individuals with advanced chronic kidney disease, including patients receiving dialysis.
- The interdisciplinary nephrology workforce needs to expand to train educators, patients, and caregivers in home dialysis care and to provide technical support for patients doing home dialysis, to facilitate more wide-spread adoption of home dialysis.
Citation
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