US Renal Data System report offers new look at home dialysis

March 16, 2022

5 minute read


Disclosures: Weinhandl does not report any relevant financial information.

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For the first time in its history, the US Renal Data System Annual Data Report included a chapter dedicated to home dialysis, offering an unprecedented view of the evolution of home therapies over the past decade.

To the nation’s credit, the overall story is excellent progress in increasing the use of home therapies – with opportunities for continued growth but also improved quality.

At the end of the line

Eric Weinhandl

In 2009, 6.8% of new dialysis patients were treated at home. In 2019, this percentage was 12.6%. As a result, the percentage of all dialysis patients who were treated at home increased from 8.9% in 2009 to 13.1% in 2019 – with more than a percentage point of that growth between 2017 and 2019 alone. .

The United States may be many years away from matching Canada or Australia in the use of home therapies, but the country is closing in on the United Kingdom, where 17.1% of dialysis patients in 2019 were treated at home.

Use of both therapies – peritoneal dialysis and home hemodialysis – has grown here, with HHD use increasing from 1.2% to 1.9% of all dialysis patients between 2009 and 2019, and PD from 7.7% to 11.2%.

Access to home therapies

Although the growth of home dialysis has been widespread across adult age groups, genders, race and ethnicity, there are persistent disparities. The use of home dialysis decreases with age. White and non-Hispanic Asian patients are at one level of utilization, while black and Hispanic patients are at a different lower level.

Socio-economics probably plays a role. While home dialysis use exceeded 30% of all dialysis patients with Medicare as a secondary payer in 2019, use was less than 10% among patients on both Medicare and Medicaid, many of whom have little or no income.

Of all Medicare-certified dialysis facilities in 2019, 47% had active home therapy programs, while an additional 8% were certified to offer at least one home modality but had no patients. About 30% of facilities offered HHD, although more than a third of them had no patients. In contrast, only one-sixth of facilities that offered PD had no patients.

Active programs tended to be small – a unique feature of home dialysis in the United States. More than half of facilities with active home therapy programs had 15 or fewer patients, and only 23% had more than 25 patients. Six out of 10 HHD programs had no more than five patients.

The preponderance of small programs presents an interesting conundrum as the country moves forward. Encouraging more facilities to offer home dialysis could put the option in front of all patients. However, medicine is dominated by the effects of practice – more patients, better results. Investing in centers of excellence could promote better outcomes with home therapies.

Early PD, late HHD

In 2019, 85% of patients who initiated PD did so within the first year after kidney failure diagnosis, and an additional 5% did so within the second year. Generally, PD is an “early” therapy. In contrast, only 43% of patients who initiated HHD in 2019 did so within the first year following the diagnosis of renal failure. Coincidentally, another 43% started HHD after 2 or more years since the kidney failure diagnosis. Generally, HHD is a “late” therapy, in part because it is used when patients are considered likely to benefit from intensification of dialysis.

In 2019, 86% of PD patients used a cycler. In other words, only 14% of patients used continuous ambulatory PD (CAPD). Simply put, no high-income country resembles the United States in this regard.

In Canada and Australia, approximately 30% of PD patients use CAPD. There may not be an “ideal” mix of CAPD and automated PD, but in the absence of randomized trials that show conclusively that one form of PD is superior to another, it is helpful to ask whether the peripheral status of the country is justified. The reality is that CAPD is hands-on therapy.

HHD intensity

HHD is a unique creature in the United States, in that daytime dialysis and low dialysate flow rates are dominant. The annual data report from the US Renal Data System offers some views of the intensity of HHD. More than 77% of HHD patients in 2019 were prescribed four or five treatments per week, with roughly equal shares of each. Only 5% of patients were prescribed six or seven treatments per week. The growing popularity of four treatments per week is an interesting development that continues to elude research scrutiny. There is little evidence, randomized or otherwise, that establishes the relative efficacy and safety of four versus three weekly treatments.

About half of HHD patients in 2019 were prescribed treatments between 2.5 and 3.5 hours, and 4% were prescribed treatments longer than 6 hours. Indeed, nocturnal HHD remains an unpopular therapy in the United States, perhaps reflecting the legacy of the Frequent Hemodialysis Network trial. Interestingly, more than a third of all patients on HHD in 2019 were prescribed less than 12 hours of therapy per week, an amount that is proportional to in-center hemodialysis. The focus is on retaining home dialysis, especially with HHD, but after accepting that home dialysis is still a “job” for patients, the question must be asked: HHD prescriptions offer they have enough benefits to justify the work?

Hospitalization rates for DP catheter complications and peritonitis steadily decreased between 2009 and 2019, as did the hospitalization rate for vascular access complications with HHD. However, some of these declines were offset by apparent increases in the rate of hospitalizations for sepsis. It is difficult to discern from the claims data what is real and what is coding drift. Eventually, access-related hospitalizations with home dialysis became less common.

The 2-year incidence of conversion from HHD to in-center hemodialysis – known as technical failure – decreased slightly between 2013 and 2018, as did the incidence of conversion from PD to hemodialysis in the center. Survival on HHD was stable, while survival on PD improved somewhat. Since 2013, the incidence of kidney transplantation has increased with both home modalities, despite the decline in the percentage of patients on the transplant waiting list.

The path to follow

The ESRD Treatment Choices payment model is the newest elephant in the room, but the past decade shows that the dialysis system is perfectly capable of steady transformation. After all, reimbursement for home dialysis has changed little since the advent of the ESRD Prospective Payment System in 2011.

The challenge now is to identify a set of strategies that will bring the country to 20% home dialysis use. The USRDS data suggests some of the following paths to take:

  • increase the use of home dialysis among elderly patients, black and Hispanic patients, and patients with low or no income;
  • investing in home dialysis centers – large programs with expert doctors and nurses who espouse the philosophy of home dialysis “for everyone”, rather than just the best candidates;
  • move PD later in the course of dialysis and move HHD earlier;
  • build enthusiasm around CAPD;
  • re-intensify HHD, with a renewed commitment to more frequent and longer treatments, including nocturnal treatments, in patients likely to benefit; and
  • increase the length of time at home, with better technology, better follow-up and more support for care partners.

The world is an oyster, and so is the dialysis system. Home dialysis is seeing great momentum, and targeted efforts to address long-standing issues that are evident in national data can further advance home therapies.

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