Of the 400,000 people on dialysis in the United States only 6 percent to 7 percent are treated with home dialysis. Yet, patients are significantly more likely to choose home dialysis if they are given that option. Home dialysis is also a more economical treatment option.
Modalities for dialysis include hemodialysis (in a kidney center or medical center, or at home) and peritoneal dialysis (at home). In-center treatments for hemodialysis are typically required three times per week. Peritoneal dialysis is an alternative way to remove waste products from blood through the blood vessels in the abdominal lining known as the periteneum. This procedure may be performed by the patient at home or while traveling.
Dr. Rajnish Mehrotra, professor of medicine in the Division of Nephrology and nephrology section head at Harborview Medical Center, compares outcomes in patients using center or home dialysis. His findings show a similar survival of patients with either of the two types of dialysis.
Outcomes research has led to recent changes in the Medicare reimbursement structure. These changes provide a strong financial incentive for promoting the use of dialysis at home. Currently less than 1 percent of Medicare beneficiaries are on dialysis but it accounts for 8 percent to 9 percent of the Medicare budget. Home dialysis costs $20,000 less than in-center treatment, which runs an average of $90,000 per year, per patient.
Working as a single practice group led by Dr. Fionnuala Cormack, a clinical instructor in medicine specializing in chronic kidney disease, the nephrologists at the University of Washington have changed the model of care for their dialysis patients.
In addition to the consolidated, in-center care they provide hemodialysis patients, once a week, physicians, nurses, and support staff meet peritoneal dialysis patients at one of the kidney Centers in the community to deliver multi-disciplinary care.
"We have built an infrastructure to seamlessly provide home dialysis to our patients in the community that we serve," said. Mehrotra.
Partnering with the UW Department of Surgery has also provided outstanding results, according to Mehrotra. A team of surgeons headed by Dr. Zoe Parr, assistant professor of surgery, received special training on laparoscopic placement of peritoneal dialysis catheters to provide better care for patients.
The Northwest Kidney Centers has helped expand the peritoneal dialysis patient population by offering a class called Choices for patients with kidney disease. Patients who attend the class are more than twice as likely to choose home care. Recently they made the class available at Harborview Medical Center, so it is even more convenient for patients.
Dr. Stuart J Shankland, professor of medicine and head of the Division of Nephrology, said that the model that Mehrotra and his colleagues have developed for patients at UW Medicine "is at the forefront of how patient care should be delivered to this population with a chronic illness."
Currently, a large, international and multi-centered clinical study called Peritoneal Dialysis Outcomes and Practice Patterns, or PDOPPS, is underway to identify how differences in practice patterns affect the ability of patients to continue to do home dialysis.
Mehrotra and Dr. Gail P. Jarvik, professor of medicine and head of the Division of Medical Genetics, are working on an ancillary study – the first and largest of its kind – to look at the genetic determinants of how peritoneal dialysis works.
"What we do in peritoneal dialysis is use naturally occurring membrane that lines our abdomen as a dialysis membrane," said Mehrotra. "But there is huge variability from person to person in how efficient that membrane is in getting rid of the toxins that accumulate in people with kidney disease. We want to test the hypothesis that this variability is determined genetically."
The longstanding tradition at UW Medicine of improving dialysis care began more than half a century ago under the late Dr. Belding Scribner, the inventor of long-term dialysis. Progress continues through the recruitment of Mehrotra to the Division of Nephrology.
"Dr. Mehrotra's research is pioneering," Shankland noted, "and partnering with Dr. Jarvik is almost certain to give insights that would help determine who the best candidates are to receive this therapy and potentially predict those who might develop complications."