Home Therapies: A Viable Option

1 Home Therapies: A Viable OptionDr. Gentiana Voinescu P/...

Author: Darleen Katrina Martin

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2 © 2015 Fresenius Medical Care. All Rights ReservedCourse Disclosure This educational program has been developed by the Medical Information and Communication Office of the Fresenius Medical Care Renal Therapies Group in collaboration with the presenter. It is intended to provide pertinent data to assist health care professionals in forming their own conclusions and making decisions. It is not intended to replace the judgment or experience of the attending physician or other medical professional. The treatment prescription is the sole responsibility of the attending physician. © 2015 Fresenius Medical Care. All Rights Reserved

3 © 2016 Fresenius Medical Care. All Rights ReservedLearning Objectives List reasons to justify the use of home dialysis therapies as a first-line option Describe why home dialysis therapies are under-utilized Explain important patient and caregiver factors to consider when choosing between PD and home HD Discuss components that contribute to a successful home therapies program © 2016 Fresenius Medical Care. All Rights Reserved

4 © 2016 Fresenius Medical Care. All Rights ReservedCourse Outline Use of home therapies vs. in-center Clinical outcomes of home therapies Prescriber and patient preferences Possible reasons for underutilization of home therapies Choosing the right modality Summary © 2016 Fresenius Medical Care. All Rights Reserved

5 Current Dialysis CultureDefault treatment is in-center hemodialysis Kt/V is the quality indicator for minimum adequacy Most patients have treatment times of 3.5 – 4 hours PD is the most common home modality In the US, our current dialysis cultures is: Default treatment is in-center hemodialysis Kt/V is the quality indicator for minimum adequacy Most patients have treatment times of 3.5 – 4 hours PD is the most common home modality © 2016 Fresenius Medical Care. All Rights Reserved

6 © 2015 Fresenius Medical Care. All Rights ReservedPoll Question Please respond to the poll question on the right-side panel of your screen by selecting your answer. Then click submit. Audience response question © 2015 Fresenius Medical Care. All Rights Reserved

7 Use of Home vs In-Center DialysisTotal Dialysis Population 466,607 The ESRD population in the Unites States continues to grow. At the end of 2013, there were 446,607 patients on dialysis, of which the majority were utilizing in-center hemodialysis with only 11.5% on some sort of home therapy. While the total numbers of home patients are continuing to grow, the percentages have remained steady over the last few years. Point prevalent counts for December 2013: Total Dialysis Population: 466,607 Home dialysis (PD and Home HD): 53,765 (11.5%) Home HD: 8,507 (1.8%) PD: 45,258 (9.0%) Reference: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: USRDS 2015 © 2016 Fresenius Medical Care. All Rights Reserved

8 © 2016 Fresenius Medical Care. All Rights ReservedModalities by Country Percentage of Patients, by Modality for 2013 In contrast to the United States, the use of home therapies is higher in many European and Pacific countries. As shown here, Hong Kong has the highest percentage of PD patients at 71.8%; and New Zealand has the highest percentage of Home HD patients at 32.2%. This indicates that home therapies can be successfully applied to a large group of dialysis patients. Reference: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: USRDS 2015 © 2016 Fresenius Medical Care. All Rights Reserved

10 © 2015 Fresenius Medical Care. All Rights ReservedPoll Question Please respond to the poll question on the right-side panel of your screen by selecting your answer. Then click submit. Audience response question © 2015 Fresenius Medical Care. All Rights Reserved

11 5-Year Survival Probability vs CancersReferences: American Cancer Society. Cancer Facts and Figures Atlanta, GA: American Cancer Society; Available from: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: Cancer Facts and Figures 2015 USRDS 2015 Cancer rates are adjusted for normal life expectancy and are based on cases diagnosed in the SEER 18 areas from , all followed through 2015. © 2016 Fresenius Medical Care. All Rights Reserved

12 Higher Mortality During Treatment GapsDeaths are increased on Mondays and Tuesdays in conventional HD, especially cardiac-related deaths1-3 Intermittent renal replacement therapies, such as conventional, thrice weekly, in-center hemodialysis increases the risk of death following a two day break in treatment. As you can see here, mortality is highest on Monday for Mon, Wed, Fri dialyzing patients, and on Tuesday for Tues, Thurs, Sat dialyzing patients. More frequent treatments, such as frequent home hemodialysis or peritoneal dialysis may impact outcomes. A more recent observational study by Foley showed similar results. References: Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int. 1999;55(4): Available from: Foley RN, Gilbertson DT, Murray T, Collins AJ. Long interdialytic interval and mortality among patients receiving hemodialysis. N Engl J Med. 2011;365(12): Available from: Zhang H, Schaubel DE, Kalbfleisch JD, Bragg-Gresham JL, Robinson BM, Pisoni RL, Canaud B, Jadoul M, Akiba T, Saito A, et al. Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality. Kidney Int. 2012;81(11): Available from: Distribution of deaths by day of the week for patients receiving dialysis on Monday–Wednesday–Friday (MWF) and Tuesday–Thursday–Saturday (TTS)3 1Bleyer AJ, et al. Kidney Int. 1999;55(4): 2Foley RN, et al. N Engl J Med. 2011;365(12): 3Zhang H, et al. Kidney Int. 2012;81(11): © 2016 Fresenius Medical Care. All Rights Reserved

13 Survival Probabilities of ModalitiesUSRDS 5-year survival probability (2008 cohort): All dialysis: 40.9% All hemodialysis: 40.2% Peritoneal dialysis: 50.6% Despite improvements in survival on dialysis over the years, only 40.2% of hemodialysis patients and 50.6% percent of peritoneal dialysis patients are alive 5 years after initiation of renal replacement therapy. Reference: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: USRDS 2015 Adjusted survival probabilities, from day one, in the ESRD population. Adjusted for age, sex, race, Hispanic ethnicity, and primary diagnosis. © 2016 Fresenius Medical Care. All Rights Reserved

14 Improved Earlier Survival with PDPD: same or better survival than in-center HD long term. Initial survival benefit of PD might be due to many factors such as preservation of residual renal function and frequent HD catheter use In a recent propensity-matched comparison of incident HD and PD patients in a single, large managed care organization, PD survival was the same or better than HD, with significant differences between modalities only evidenced in the first 2-3 years following initiation of therapy2. Population-averaged adjusted patient survival for propensity score-matched hemodialysis (HD) and peritoneal dialysis (PD) patients by method of analysis. The shaded areas reflect where the point-wise differences in the two survival curves differ (P<0.05). Study limitations: select population of patients that are not necessarily representative of the US Dialysis population. References: Kumar VA, Sidell MA, Jones JP, Vonesh EF. Survival of propensity matched incident peritoneal and hemodialysis patients in a United States health care system. Kidney Int. 2014;86(5): Available from: Kumar VA, et al. Kidney Int. 2014;86(5): © 2016 Fresenius Medical Care. All Rights Reserved

15 Improved Survival with Home HDHome dialysis (peritoneal and HD) has similar survival outcomes to in-center HD (top). Home HD has significantly better survival compared to in-center HD and PD (bottom). Mortality risk compared to in-center HD: 53% lower risk with Home HD 20% lower risk with PD <3 years 33% higher risk with PD >3 years In a recent study, Marshall modeled survival of 6,419 patients with 3,254 deaths over 20,042 patient-years of follow-up. Patients treated with PD and facility HD are similar; those on home HD are younger and healthier. Compared to facility HD, home dialysis (as a unified category) associates with an overall 13% lower mortality risk. Home HD associates with a 52% lower mortality risk. PD associates with a 20% lower mortality risk in the early period (<3 years) that is offset by a 33% greater mortality risk in the late period (>3 years), with no overall net effect. Reference: Marshall MR, Walker RC, Polkinghorne KR, Lynn KL. Survival on home dialysis in New Zealand. PLoS One. 2014;9(5):e Available from: Marshall MR, et al. PLoS One. 2014;9(5):e96847 © 2016 Fresenius Medical Care. All Rights Reserved

16 PD First: PD Followed by HD Can Improve OutcomesOver 10 years, survival of in-center HD and PD patients were not significantly different (left) However, if switched to HD when appropriate, there was a survival advantage for patients started on PD (right) Reference: Van Biesen W, Vanholder RC, Veys N, Dhondt A, Lameire NH. An evaluation of an integrative care approach for end-stage renal disease patients. J Am Soc Nephrol. 2000;11(1): Available from: Van Biesen W, et al. J Am Soc Nephrol. 2000;11(1):116-25 © 2016 Fresenius Medical Care. All Rights Reserved

17 PD Mortality Depends on Center ExperienceA center's experience with PD strongly impact PD outcomes. Technique failure and mortality decrease with increased numbers of patients treated. With centers where more than 60% of patients were initiated with PD as the reference group, there was a trend to increased risk of death where PD was less likely to be the initiating modality. An even stronger impact was described for risk of technique failure (above slide) with a 75% increased risk of technique failure for those centers initiating less than 30% of patients on PD compared to those choosing PD for over 60% of patients. Reference: Schaubel DE, Blake PG, Fenton SS. Effect of renal center characteristics on mortality and technique failure on peritoneal dialysis. Kidney Int. 2001;60(4): Available from: Schaubel DE, et al. Kidney Int Oct;60(4): © 2016 Fresenius Medical Care. All Rights Reserved

18 © 2016 Fresenius Medical Care. All Rights ReservedPeritoneal Dialysis vs. In-Center HD*: Hospitalization, CV Outcomes, and Access-Related Interventions In this next section we will discuss outcomes with Peritoneal dialysis. Outcomes of home HD will be discussed in a later presentation. *Outcomes of home HD compared to in-center HD will be discussed in a later presentation © 2016 Fresenius Medical Care. All Rights Reserved

19 PD vs. HD: HospitalizationsAdmissions per patient year: 1.74 HD* and 1.67 PD Hospital days per patient year: 11.2 HD* and 11.8 PD Adjusted hospitalization rates and days by modality Over the past decade, the frequency of hospital admissions and resulting number of hospital days for ESRD patients have declined gradually, but fairly consistently. As shown in Figure 5.1, in 2013, the adjusted rate of admission for hemodialysis (HD) patients decreased to 1.74 per patient year (PPY), as compared to 2.1 in 2005, which is a reduction of 19.0%. During that same period, rates for peritoneal dialysis (PD) patients fell about 15.0% (1.67 in 2013 from 2.0 in 2005). Continuing a downward trend seen since 2005, the number of total hospital days per patient year among all dialysis patients has decreased, from 14.6 to From 2005 to 2013, hospital days PPY decreased to 11.2 for HD patients and 11.8 for PD patients. This data suggests that PD patients have fewer hospitalizations, but more hospital days, than their HD counterparts. Reference: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: USRDS 2015 *USRDS HD data encompasses both in-center (98%) and home HD (2%) patients (Period prevalent ESRD patients; adjusted for age, sex, race, & primary diagnosis; ref: ESRD patients, 2010.) © 2016 Fresenius Medical Care. All Rights Reserved

20 PD vs. HD: All-Cause and Cause-Specific Hospitalization RatesHospitalization rates have continued to decrease for both PD and HD* Adjusted all-cause & cause-specific hospitalization rates, by modality All-cause hospitalization rates among adult HD patients decreased by 17.5% (2.11 to 1.74 admissions per patient year) from 2005 to For peritoneal dialysis patients, the all-cause hospitalization rate decreased 17.7% (2.03 to 1.67 admissions per patient year) from 2005 to 2014. While the overall trends of decreasing hospitalization rates are encouraging, it is plausible that these global and cause-specific declines were influenced at least in part by changes in clinical care practices, CMS rules and terminology, and policies that emphasize greater utilization of ambulatory care services. Reference: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: USRDS 2015 *USRDS HD data encompasses both in-center (98%) and home HD (2%) patients Period prevalent ESRD patients; adjusted for age, sex, race, & primary diagnosis; ref: ESRD patients, 2010. © 2016 Fresenius Medical Care. All Rights Reserved

21 PD vs. HD: Cardiovascular DiseasePD patients are 20% less likely than HD* patients to have any cardiovascular comorbidity ESRD patients have a high burden of cardiovascular disease across a wide range of conditions. Stable atherosclerotic heart disease (ASHD) and congestive heart failure (CHF) are the two major leading cardiovascular diseases present in ESRD patients. However, acute myocardial infarction (AMI), cerebrovascular accident/transient ischemic attack (CVA/TIA), peripheral arterial disease (PAD), atrial fibrillation (AFIB), sudden cardiac arrest and ventricular arrhythmias (SCA/VA) are also common. The prevalence of these cardiovascular diseases is highest among ESRD patients who receive hemodialysis followed by peritoneal dialysis References: United States Renal Data Systems USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Available from: USRDS 2015 *USRDS HD data encompasses both in-center (98%) and home HD (2%) patients Unadjusted 2005 point prevalent ESRD patients age 20 years and older © 2016 Fresenius Medical Care. All Rights Reserved

22 PD vs HD: Risk of Access-Related InterventionsPD was associated with a significantly lower risk of access-related interventions compared to HD (P < 0.001) Retrospective analysis of 152 incident dialysis patients Mean dialysis access-related cost/pt-year at risk was lowest for PD patients Modality N # of access-related interventions per pt-year at risk (mean ± SD) Mean dialysis access-related cost per pt-year at risk (*US$) PD 65 1.54 ± 0.73 1535 HD AVF 45 2.38 ± 2.06 2022 HD CVC 42 3.67 ± 2.50 5471 Reference: Coentrão LA, Araújo CS, Ribeiro CA, Dias CC, Pestana MJ. Cost analysis of hemodialysis and peritoneal dialysis access in incident dialysis patients. Perit Dial Int. 2013;33(6): Available from: Coentrao LA, et al. Perit Dial Int Nov-Dec;33(6):662-70 *Based on conversion 1€ = 1.3US$ © 2016 Fresenius Medical Care. All Rights Reserved

24 Nephrologists see an Increased Role for Home ModalitiesPrescribers were asked to select an ideal mix of modalities that would maximize outcomes for 10 million patients Respondents in the US cohort felt that home therapies should be used in 45% of the population Nephrologists in the US and Canada have been recently polled regarding their opinions on the optimal utilization of HD and PD. Their opinions were mostly influenced by patient preference, quality of life, morbidity and mortality and not by reimbursement. In Canada, the actual vs expressed optimal utilization of modality are very close, while in the US they are markedly different. The results suggest that US nephrologists would support more PD and HHD, but have not. References: Mendelssohn DC, Mullaney SR, Jung B, Blake PG, Mehta RL. What do American nephrologists think about dialysis modality selection? Am J Kidney Dis. 2001;37(1): Available from: Jung B, Blake PG, Mehta RL, Mendelssohn DC. Attitudes of Canadian nephrologists toward dialysis modality selection. Perit Dial Int. 1999;19(3): Available from: 1Mendelssohn DC, et al. Am J Kidney Dis Jan;37(1):22-29 2Jung B, et al. Perit Dial Int. 1999;19(3):263-8 © 2016 Fresenius Medical Care. All Rights Reserved

25 © 2015 Fresenius Medical Care. All Rights ReservedPoll Question Please respond to the poll question on the right-side panel of your screen by selecting your answer. Then click submit. Audience response question © 2015 Fresenius Medical Care. All Rights Reserved

26 Most Nephrologists Would Choose Home Therapies for ThemselvesIf nephrologists’ kidneys failed and there was a 5-year wait for a transplant, 91% would choose home therapies Reference: Merighi JR, Schatell DR, Bragg-Gresham JL, Witten B, Mehrotra R. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int. 2012;16(2): Available from: Merighi JR, et al. Hemodial Int Apr;16(2):242-51 © 2016 Fresenius Medical Care. All Rights Reserved

27 Patients Choose Home Therapy When Properly Educated70 patients were randomized to receive standard care alone or standard care with educational intervention Within the subgroup of patients who were uncertain or planning to start in-center care at enrollment, education dramatically increased the use of home therapy Standard Care Standard Care +Education Planning to start self-care dialysis at baseline 0% Planning to start self-care dialysis at study completion 16.7% 64.2% This is consistently seen throughout the literature. Reference: Manns BJ, Taub K, Vanderstraeten C, Jones H, Mills C, Visser M, McLaughlin K. The impact of education on chronic kidney disease patients’ plans to initiate dialysis with self-care dialysis: a randomized trial. Kidney Int. 2005;68(4): Available from: Manns BJ, et al. Kidney Int Oct;68(4): © 2016 Fresenius Medical Care. All Rights Reserved

28 © 2016 Fresenius Medical Care. All Rights ReservedGreater Patient Satisfaction With Home Therapies Compared to In-Center HD Patients receiving PD were 1.5 times more likely to rate their care as “excellent” than those using in-center HD1 Patients and caregivers perceive that home HD offers the opportunity to thrive; improves freedom, flexibility, and well-being; and strengthens relationships2 Patients receiving PD were 1.5 times more likely to rate their care as “excellent” than those using in-center HD Patients and caregivers perceive that home HD offers the opportunity to thrive; improves freedom, flexibility, and well-being; and strengthens relationships References: Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, Powe NR. Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA. 2004;291(6): Available from: Walker RC, Hanson CS, Palmer SC, Howard K, Morton RL, Marshall MR, Tong A. Patient and Caregiver Perspectives on Home Hemodialysis: A Systematic Review. Am J Kidney Dis. 2015;65(3): Available from: 1Rubin HR, et al. JAMA. 2004;291(6): 2Walker RC, et al. Am J Kidney Dis. 2015;65(3): © 2016 Fresenius Medical Care. All Rights Reserved

30 © 2015 Fresenius Medical Care. All Rights ReservedPoll Question Please respond to the poll question on the right-side panel of your screen by selecting your answer. Then click submit. Audience response question © 2015 Fresenius Medical Care. All Rights Reserved

31 Nephrologists are not Well Trained in Home TherapiesIn a survey of 67 nephrology fellows: 50% were from programs offering 3 or fewer months of exposure to outpatient hemodialysis 25% reported no exposure to PD Of more concern, 25% reported no "official rounds" with an attending nephrologist on dialysis patients In the US, nephrology training programs generally do not offer trainees sufficient exposure to care for HD and PD patients. A poll of second year nephrology fellows in the US (n = 67) revealed that 50% were from programs offering 3 or fewer months of exposure to outpatient HD and 25% reported no exposure to PD. Furthermore, 25% reported no formal rounds with an attending nephrologist on dialysis patients. If nephrologists are to take their appropriate place as leaders of the care delivery team, nephrology fellowships must be restructured with appropriate emphasis placed on the comprehensive care of ESRD and CKD patients. Reference: Nissenson AR, Agarwal R, Allon M, Cheung AK, Clark W, Depner T, Diaz-Buxo JA, Kjellstrand C, Kliger A, Martin KJ, et al. Improving outcomes in CKD and ESRD patients: carrying the torch from training to practice. Semin Dial. 2004;17(5): Available from: Nissenson AR, et al. Semin Dial. 2004;17(5):380-97 © 2016 Fresenius Medical Care. All Rights Reserved

32 Nephrologists are not Well Trained in Home TherapiesSurvey of ASN members: Gave high importance to PD and home HD training However, physicians did not feel well trained or competent regarding home therapies Reference: Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol. 2010;5(3): Available from: Berns JS, et al. Clin J Am Soc Nephrol Mar;5(3):490-6 © 2016 Fresenius Medical Care. All Rights Reserved

33 Physician Awareness and TrainingIn a survey of US nephrologists between 2004 and 2008, the predominant therapies used were in-center HD or PD Utilization of dialysis therapies other than standard hemodialysis is dependent, in part, on training experience. References: Merighi JR, Schatell DR, Bragg-Gresham JL, Witten B, Mehrotra R. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int. 2012;16(2): Available from: Merighi JR, et al. Hemodial Int Apr;16(2):242-51 © 2015 Fresenius Medical Care. All Rights Reserved

34 Patients Are Not Informed About Their Treatment OptionsPatient self-reported knowledge of the various dialysis modalities, transplant, and conservative management is quite varied, with no modality receiving a majority “A lot of knowledge rating”. APD, automated peritoneal dialysis (cycler); CAPD, continuous ambulatory peritoneal dialysis; CD, conventional in-center hemodialysis; CM, conservative management; HHD, home hemodialysis; NCD, nocturnal in-center dialysis; transplant, kidney transplantation. Reference: Prakash S, McGrail A, Lewis SA, Schold J, Lawless ME, Sehgal AR, Perzynski AT. Behavioral stage of change and dialysis decision-making. Clin J Am Soc Nephrol. 2015;10(2): Available from: Prakash S, et al. Clin J Am Soc Nephrol. 2015;10(2): Survey of 55 adult CKD patients © 2016 Fresenius Medical Care. All Rights Reserved

35 Patients Are Not Informed About Their Treatment OptionsSystematic review of 18 qualitative studies regarding decision-making and choice of dialysis modality Lack of information 11 of the 18 studies reported that patients did not have adequate information regarding treatment options Medical decisions 17 of the 18 studies reported that decisions regarding modality were made for patients by HCPs In 14 of the studies, providers also framed the choices in a way to encourage HD Reference: Morton RL, Tong A, Howard K, Snelling P, Webster AC. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BMJ. 2010;340:c112. Available from: Morton RL, et al. BMJ Jan 19;340:c112 © 2016 Fresenius Medical Care. All Rights Reserved

36 Patients Are Not Involved in the Modality DecisionWhen asked who made the modality decision, patients on HD reported that the primary decision was made by the physician PD patients were more likely to choose their own therapy Reference: Stack AG. Determinants of modality selection among incident US dialysis patients: results from a national study. J Am Soc Nephrol. 2002;13(5): Available from: Stack AG. J Am Soc Nephrol May;13(5): National survey of new ESRD patients (n=3793) © 2016 Fresenius Medical Care. All Rights Reserved

37 Patients Are Not Involved in the Modality DecisionWhen asked who makes the modality decision, nurses perceived that most decisions are made by the physician Survey of dialysis nurses (n=101) Reference: Schiller B, Neitzer A, Doss S. Perceptions about renal replacement therapy among nephrology professionals. Nephrol News Issues. 2010;24(10):36, 38, 40 passim. Available from: Schiller B, et al. Nephrol News Issues Sep;24(10):36-40 © 2016 Fresenius Medical Care. All Rights Reserved

38 New Paradigm for Choosing Treatment OptionsPhysicians may rely on outdated paradigms when discussing dialysis modalities Default may be PD or conventional HD Golper and Schreiber suggest the following paradigm for choosing treatment options 1st Kidney replacement therapy vs. maximum conservative care 2nd Pre-emptive transplantation vs. dialysis 3rd Home vs. In-Center dialysis 4th PD vs. HD References: Young BA, Chan C, Blagg C, Lockridge R, Golper T, Finkelstein F, Shaffer R, Mehrotra R. How to overcome barriers and establish a successful home HD program. Clin J Am Soc Nephrol. 2012;7(12): Available from: Golper TA, Schreiber MJ. The Course of Therapy – Changing the Paradigm. In: Fadem SZ, ed. Issues in Dialysis. New York: Nova Science Publishers; 2012: Available from: https://www.novapublishers.com/catalog/product_info.php?products_id=29800. Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12): Golper T, Schreiber M. In: Issues in Dialysis, 2012, p35–47 © 2015 Fresenius Medical Care. All Rights Reserved

39 Improving Patient Choice and EducationWe must educate for all CKD stage 4 patients Physician should discuss home dialysis options CKD nurse educator must be well versed in home therapy Refer early to Kidney Options or Treatment Options Program Meet surgeon prior to need for PD catheter or AVF Reinforce decision at each visit Not being prepared leads to a HD catheter and in-center HD Key to success = start early! Reference: Bernardini J, Price V, Figueiredo A. Peritoneal dialysis patient training, Perit Dial Int. 2006;26(6): Available from: Bernardini J, et al. Perit Dial Int. 2006;26(6): © 2016 Fresenius Medical Care. All Rights Reserved

40 © 2015 Fresenius Medical Care. All Rights ReservedPoll Question Please respond to the poll question on the right-side panel of your screen by selecting your answer. Then click submit. Audience response question © 2015 Fresenius Medical Care. All Rights Reserved

41 Choosing the Right ModalityNow that we know that home therapies are good and we have insights into why they are under-utilized, let’s look at factors that will help guide our treatment recommendations © 2016 Fresenius Medical Care. All Rights Reserved

42 Choosing the Right ModalityThere is insufficient medical evidence to support a general modality preference for all patients The initial modality choice should be made primarily by the well-informed patient © 2015 Fresenius Medical Care. All Rights Reserved

43 Rationale for Choosing PD as First Choice for Home Dialysis TherapyPreservation of renal function Preservation of QoL and independence Better outcome data, especially early in dialysis Safety Simplicity of training Time for education and preparation for future therapies: Home hemodialysis Transplantation Time to create a native AV fistula and prevent HD catheter use References: Hirsch DJ, Jindal KK, Schaubel DE, Fenton SS. Peritoneal dialysis reduces the use of non native fistula access in dialysis programs. Adv Perit Dial. 1999;15: Available from: Hirsch DJ, et al. Adv Perit Dial. 1999;15: © 2016 Fresenius Medical Care. All Rights Reserved

44 © 2016 Fresenius Medical Care. All Rights ReservedRationale for Choosing Home HD as First Choice for Home Dialysis Therapy Better outcomes than in-center 3x per week HD: May confer a survival advantage1-2 Improved QoL, blood pressure, and phosphate control3-4 Reduced risk of infectious complications2 Reduction in dialysis related side-effects5 Convenience and flexibility for patient5-6 Less dietary and fluid restrictions for patients using frequent dialysis5 References: Kjellstrand CM, Buoncristiani U, Ting G, Traeger J, Piccoli GB, Sibai-Galland R, Young BA, Blagg CR. Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years. Nephrol Dial Transplant. 2008;23(10): Available from: Marshall MR, Hawley CM, Kerr PG, Polkinghorne KR, Marshall RJ, Agar JWM, McDonald SP. Home hemodialysis and mortality risk in Australian and New Zealand populations. Am J Kidney Dis. 2011;58(5): Available from: Chertow GMG, Levin NNW, Beck GGJ, Depner TTA, Eggers PWP, Gassman JJJ, Gorodetskaya I, Greene T, James S, Larive B, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24): Available from: Rocco M V, Lockridge RS, Beck GJ, Eggers PW, Gassman JJ, Greene T, Larive B, Chan CT, Chertow GM, Copland M, et al. The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial. Kidney Int. 2011;80(10): Available from: Masterson R. The advantages and disadvantages of home hemodialysis. Hemodial Int. 2008;12 Suppl 1:S16-S20. Available from: Thodis ED, Oreopoulos DG. Home dialysis first: a new paradigm for new ESRD patients. J Nephrol. 2011;24(4): Available from: 1Kjellstrand CM, et al. Nephrol Dial Transplant. 2008;23(10): Marshall MR, et al. Am J Kidney Dis. 2011;58(5): 3Chertow GMG, et al. N Engl J Med. 2010;363(24): Rocco M V, et al. Kidney Int. 2011;80(10): 5Masterson R. Hemodial Int. 2008;12 Suppl 1:S16-S20. 6Thodis ED, Oreopoulos DG. J Nephrol. 2011;24(4): © 2016 Fresenius Medical Care. All Rights Reserved

45 Factors Patients Consider When Choosing ModalitiesData derived from six focus groups involving 27 patients and 18 relatives Modality Advantages Disadvantages In-center HD Feels secure (supervision by known professionals) Freedom from illness at home and on dialysis free days Socializing with staff and other patients Transport time to clinic Fixed dialysis time and no flexibility Limitations on holidays or family time Home HD Greater flexibility No travel time to a facility Better social life Possibility of continuing a career Possibility of night-time treatment Takes up space in the home and is unsightly Technical problems and noise Difficult to take equipment on holidays PD (all forms) Good for those who fear needles PD bags are heavy Reference: Lee A, Gudex C, Povlsen J V, Bonnevie B, Nielsen CP. Patients’ views regarding choice of dialysis modality. Nephrol Dial Transplant. 2008;23(12): Available from: Lee A, et al. Nephrol Dial Transplant Dec;23(12):3953-9 © 2016 Fresenius Medical Care. All Rights Reserved

46 Factors for Nephrologists to Consider When Prescribing PDThe non-profit Medical Education Institute developed the MATCH-D for home dialysis to help nephrologists and dialysis staff identify and assess candidates for home dialysis therapies (namely PD and HHD). Column 1 (far left) creates triage criteria for patients who would likely be successful on home regimens. Column 2 (middle) suggests solutions to common home dialysis barriers. Column 3 (far right) describes contraindications for independent home treatment. Match-D also has a home hemodialysis brochure. We will discuss that in a later presentation. Reference: Medical Education Institute. Methods to Assess Treatment Choices for Home Dialysis, Version 4.; Available from: *Match-D for home HD will be discussed in a later presentation Methods to Assess Treatment Choices for Home Dialysis, Version 4.; 2013 © 2016 Fresenius Medical Care. All Rights Reserved

47 Home HD and PD Programs are ComplementaryDoes a robust PD program hinder growth of HHD? Do HHD programs grow by cannibalizing PD? Not necessarily, both can grow simultaneously Educating patients about therapy choice is key “Wellbound model”- 83.5% PD, 16.6% HHD 986 patients referred for home therapy evaluation 45.8% (452) chose home therapy of which 79.2% (358/452) chose PD Wellbound Model: WellBound, a subsidiary of Satellite Healthcare, Inc., is the first healthcare services company to focus exclusively on self-care dialysis therapy options for people with chronic kidney disease (CKD). The company’s unique expertise in pre-dialysis patient wellness education and personalized self-care training facilitates a higher quality of life and improved clinical outcomes for CKD patients, while enabling physician partners to expand the level of care they provide to CKD patients. WellBound has established a growing network of “Centers of Excellence” to deliver wellness education and the full spectrum of self-care dialysis options, including peritoneal dialysis and daily home hemodialysis. Reference: Burkart J. Role of peritoneal dialysis in the era of the resurgence of home hemodialysis. Hemodial Int. 2008;12 Suppl 1:S51-S54. Available from: Burkart J. Hemodial Int Jul;12 Suppl 1:S51-4 © 2016 Fresenius Medical Care. All Rights Reserved

48 © 2016 Fresenius Medical Care. All Rights ReservedSummary Home therapies (PD and Home HD) may provide significant survival benefits compared to in-center HD Both therapies are underutilized 10.8% of patients are currently using home therapies US nephrologists believe that PD or home HD are the preferable modalities for 45% of their patients There is potential to grow home therapies and improve patient outcomes Patient and provider training on modality options is essential © 2016 Fresenius Medical Care. All Rights Reserved

49 © 2015 Fresenius Medical Care. All Rights ReservedFresenius Renal Therapies Group, a division of Fresenius Medical Care North America 920 Winter Street • Waltham, MA Fresenius Medical Care, the triangle logo, the Advanced Renal Education Program, and the AREP logo are trademarks of Fresenius Medical Care Holdings, Inc., or its affiliated companies. © 2016 Fresenius Medical Care, All Rights Reserved. P/N Rev E 02/2016 © 2015 Fresenius Medical Care. All Rights Reserved

Home Therapies: A Viable Option

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