Home dialysis enters new era

MEDICAL MATTERS

October 21, 2005|By JUDY FOREMAN

To take over for her failing kidneys, Madeleine Therrien, 63, of Merrimack, N.H., tried a home dialysis system that flushed her abdomen with fluids several times a day. But, as often happens with this kind of treatment, known as peritoneal dialysis, she wound up in the hospital with a painful abdominal infection.

So she switched to hemodialysis three times a week at a clinic, which was effective but meant sitting for four hours each time, hooked up to a machine that cleansed her blood. Last year, she had a kidney transplant, but her body rejected it within days, and she wound up back in the hemodialysis clinic.

Since then, she's discovered a new generation of home hemodialysis treatments, and she's the healthiest she's been in years. By day, she runs the roadside stand where she and her husband, Skip, sell the vegetables he grows on their 4-acre farm. Six evenings a week, he hooks her up to a machine while they watch TV or play cards for two hours and 20 minutes.

Recent, vast improvements in home hemodialysis machines are beginning to revolutionize the treatment of people like Therrien.

Until now, nearly all of the nation's 300,000 kidney failure patients have had to get treatment in a dialysis clinic, in part because old-style home hemodialysis meant learning to program a complicated, refrigerator-sized machine, and redoing the plumbing and rewiring the house to assure pure enough water and sufficient electricity.

But the advent of these "dramatically improved machines, designed to be extremely user-friendly," means as many as 40 percent of patients could safely dialyze at home, said Dr. Allen Nissenson, director of the dialysis program at the David Geffen School of Medicine at UCLA.

This will become increasingly important in years to come. By 2030, as a result of the aging baby boomer population and the continuing epidemic of diabetes (a leading cause of kidney failure), more than 2 million Americans will be on dialysis or will have had a kidney transplant, according to the U.S. Renal Data System, a government-funded national database.

In addition to the convenience factor, there's also hope - though not yet solid proof - that home hemodialysis will save lives.

Preliminary data suggest that dialysis more than three days a week, which more closely reflects the kidney's normal 24/7 job, can protect heart function, help reduce anemia and prevent some of the bone loss that often accompanies kidney failure. It may save money as well, because patients may need fewer hospitalizations for complications and labor costs are cheaper.

So far, the new home dialysis system is working quite well for about 400 patients nationwide, including Therrien. Her blood pressure is down and her weight is, too, because she's not bloating with excess fluid. All her lab tests are better, and most important, she said, she never has "that lousy feeling of being full of toxins."

To see whether this regimen is effective for others as well, the National Institutes of Health is starting a three-year, multicenter study. The results are considered critical in persuading Medicare, which usually pays for hemodialysis only three times a week, to pay for the six-day treatments.

Thrice-weekly hemodialysis costs $60,000 a year per patient, including hospitalizations for complications.

Kaiser Permanente, California's giant health care system, believes that frequent home hemodialysis (also called "short daily home" hemodialysis) will not only improve patient outcomes, but also save $10,000 a year per patient, said Dr. Peter Crooks, director of the renal program for Kaiser Permanente Southern California. The plan now has a dozen patients on the home program and will soon have more.

In addition to the NxStage system that Therrien uses - which received Food and Drug Administration approval in June - Aksys home hemodialysis machines have been available since 2002. A system by Renal Solutions is also approved, though the company doesn't yet have FDA permission to advertise the machine for home use. Other giants in the field, including Da Vita and Fresenius Medical Care, are also pursuing home hemodialysis.

For patients now using home peritoneal dialysis - the kind Therrien used before her infection - switching to home hemodialysis may become a natural next step, said Dr. Bernard Jaar, a kidney specialist at the Nephrology Center of Maryland in Baltimore.

A study of more than 1,000 patients that Jaar's team published in August found that by the second year of peritoneal dialysis, the death rate was 50 percent higher than with hemodialysis, suggesting, he said, that the trend toward home hemodialysis "should be encouraged."

Even if the government does decide to spring for more frequent hemodialysis and the home machines that make it feasible, home hemodialysis won't eliminate the need for some center-based treatment.

Patients who live alone may not have the help they need to insert the two needles (one for blood coming out of the body, one for blood going back in) needed to hook them up to the machine. Some patients have medical conditions, like severe heart disease, arthritis or bad vision, that also limit their capability. And some like the social value of chatting with other patients in a center.

But at least those like Therrien, who want another option, will have one.

Judy Foreman's column appears every other week. Past columns are available at myhealthsense .com.

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