Transitioning patients from peritoneal dialysis (PD) to home hemodialysis (HHD) is a critical yet often overlooked process in nephrology. As the field evolves, it is imperative for nephrologists to understand this transition to provide optimal care for their patients. This is not only about moving from one form of dialysis to another but proactively leading the change in a way that aligns with the patient’s health status, lifestyle, and long-term treatment goals.
Understanding the Need for Transition
Many patients on PD reach a point where the therapy no longer suffices. According to data from the United States Renal Data System (USRDS), nearly half of the patients on PD transition off therapy within three years. This is not a failure, but an inherent part of PD and a patient’s evolving needs. PD is an effective treatment, but it has a limited duration. Recognizing when PD can no longer maintain a patient’s health is crucial for ensuring a smooth transition to HHD.
Debunking Myths
Healthcare providers often hesitate to recommend home hemodialysis due to misconceptions regarding its feasibility. Beliefs that HHD is too complex or requires a high level of patient support biases who is considered for the modality. Today, these barriers are more perception than reality. Advances in technology, training, and patient education have made it easier than ever to manage HHD, debunking myths surrounding its complexity and accessibility. For example, modern dialysis equipment like the Outset Medical Tablo® Hemodialysis System, designed for both home and clinical settings, has significantly simplified the process, making it more user-friendly and less burdensome for patients, care partners, and healthcare professionals alike.
Additionally, many patients who have been successfully managing their peritoneal dialysis at home are accustomed to frequent treatments, extensive supply management, and stringent lifestyle adjustments. Transitioning to HHD may actually reduce some of these burdens, as it can offer more flexibility and potentially fewer restrictions in their daily lives. Therefore, the belief that HHD would be more demanding for these patients is often unfounded, as they have already demonstrated their ability to manage home therapies effectively.
Practical Guidance for Healthcare Professionals: Steps to Manage the Transition
- Patient Education: Being proactive and educating all PD patients on the natural course of the therapy and possibility of a home transition to HHD is crucial. Patients who have successfully managed PD are often ideal candidates for HHD. Patients need to be informed that the transition from PD to HHD is a not a failure, but an expected progression of care.
- Comprehensive Training: Nephrologists should ensure that both patients and care partners are thoroughly trained in advance on managing the transition to HHD. This includes familiarizing them with the equipment and understanding the differences they will experience as they transition to hemodialysis at home. Training should capitalize on the patient’s expertise in self-care to build confidence for successful transition and fill knowledge gaps around their new HHD device and therapy, such as cannulation. Proactively addressing any lingering reservations about HHD can help patients and their families approach their transition with positivity.
- Home Setup: Preparing the patient’s home environment is one of the easiest steps. The patient likely has the necessary infrastructure, such as space for the machine and supplies. Home site and set up assessments support installation of new equipment and facilitate a smooth transition to HHD.
Overcoming Barriers
One significant challenge in this transition is the current healthcare system’s inertia. For decades, most dialysis patients are funneled into in-center hemodialysis by default or as an initial modality. This is often because they are not adequately informed of all their options prior to starting dialysis, or the infrastructure for home hemodialysis is not available in their area. To address this, nephrologists must take the lead in driving the transition to HHD. A team-based approach involving nurses, social workers, case managers, health systems and dialysis providers is essential to increase HHD access and support patients throughout this process.
Partnerships with hospitals and healthcare organizations have already begun to play a crucial role in facilitating the transition. For instance, some hospitals have begun implementing direct-to-home programs where PD patients are educated on HHD before leaving the hospital and trained in their homes upon discharge, thus bypassing the need for in-center dialysis altogether. This coordinated, patient-centered approach not only better supports patients but also helps reduce hospital readmissions and provides a path to improved patient outcomes.
Achieving a Seamless Transition
The move from PD to HHD can be seamless when approached with the right mindset and tools. By addressing misconceptions, providing practical guidance, and fostering a collaborative healthcare environment, nephrologists can help their patients navigate this transition successfully, leading to a better quality of life. As nephrology continues to evolve, embracing these transitions will be key to providing patient-centered care that meets the diverse needs of those living with kidney disease.
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Michael Aragon, MD
Michael Aragon, M.D., is board certified in Internal Medicine and Nephrology, serving as the Chief Medical Officer at Outset Medical, where he leads clinical strategy and medical education initiatives to advance patient-centered care in dialysis. His clinical research has been focused on human factors and the expansion of dialysis options for patients with renal disease.
