People Are Choosing Kidney Dialysis at H


Come January, there may be many more people like Mary Prochaska.

Ms. Prochaska, 73, a retired social worker in Chapel Hill, N.C., has advanced chronic kidney disease and relies on dialysis to filter waste from her blood while she awaits a kidney transplant, her second. But she no longer visits a dialysis center three times a week, the standard treatment. There, nurses and technicians monitored her for four hours while a machine cleansed her blood.

Instead, she has opted for dialysis at home. “It’s easier on your body and better for your health,” she said. “And far better than exposing yourself to whatever you might get from being in a group of people” at a center during a pandemic.

With her husband’s help, Ms. Prochaska performs peritoneal dialysis; after a surgeon implanted a tube in her side, her abdominal lining acts as the filter. After getting training for a couple of weeks, she began using a home machine called a cycler to remove excess fluid and impurities.

“It automatically does the pumping in and pumping out, five times a night, while you sleep,” she said. “When you get up, you’re done. It’s like having a normal life.”

Some patients begin dialysis when a health crisis sends them to an emergency room. With scant time to explore the decision or undergo the necessary training to dialyze at home, they wind up at centers.

But many don’t seem to know they have alternatives. In a 2016 study, almost half the patients receiving in-center hemodialysis said it had not been their choice.

“There are patients who don’t know they could do dialysis at home,” said Dr. Suzanne Watnick, chief medical officer of Northwest Kidney Centers in Seattle. “To me, that’s a travesty. Patients who’ve gotten education about the different modalities have a markedly higher rate of participation in home dialysis.”

But the training that physicians receive may not emphasize that option. Moreover, once patients grow accustomed to a center, “where everything is done for you, you’re not likely to take on the responsibility of doing it at home,” Mr. Knight said. Home dialysis can seem daunting or frightening, and neither medical practices nor for-profit centers have had much motivation, at least financially, to promote it.

Thirty percent of them soon will. Medicare will increase its monthly payments for each patient that receives home dialysis, starting at 3 percent the first year, decreasing thereafter. Practices and dialysis clinics will also have their reimbursements adjusted up or down depending on their total rates of home dialysis and transplantation.

Several new voluntary programs will boost incentives, too. Starting in April, Medicare will pay providers a $15,000 bonus, over three years, when a patient receives a successful kidney transplant. Another measure provides greater support for living kidney donors.

Whether such incentives will substantially increase home dialysis and transplants remains an open question.

Some providers, noting that the penalties could outweigh the bonuses, aren’t pleased to fall into the 30 percent of covered practices or centers, randomly assigned by ZIP code. “The average nephrologist is going to have a pay cut,” Dr. Watnick said.

Moreover, not all older kidney patients can or want to dialyze at home. “They may have some degree of cognitive impairment” or be too frail to lift bags of solution, said Dr. Gerald Hladik, chief of nephrology at the University of North Carolina. They need room to store supplies and a clean, private dialysis space.

Even with ample discussion and education, it’s unclear what proportion might eventually choose home dialysis. Perhaps 25 to 50 percent, Dr. Watnick suggested — “but we don’t know.”

Although the new Medicare model excludes nursing home residents and people with dementia, the choice will otherwise rest with patients. Especially during a pandemic, “we’re in favor of patients having the choice to go home,” Mr. Knight said. “But not in favor of pushing people to go home.”

Some older people with multiple illnesses may decide to forgo dialysis altogether. Wherever performed, it’s physically and psychologically onerous, and survival decreases at older ages.

Dr. Hladik’s 75-year-old father, for instance, wanted to spend his remaining days at home with his dog or at the beach. He chose conservative management to control his symptoms and lived comfortably for a year and a half without dialysis.

But home dialysis has worked well for Jorge Moreira, 65, a bookkeeper in Burien, Was. As his kidney disease advanced four years ago, he began dialysis at a Northwest Kidney Centers’ clinic.

He found it arduous to arrive at 5:30 a.m. three days a week so that he could finish by 9:30 and go to his office, and he suffered painful leg cramps. A technician suggested he look into peritoneal dialysis; his doctors agreed.



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