Originally (45 years ago), hemodialysis was offered as a home modality to afford lower cost treatments to the patient. Thrice weekly, 6-8 hours at clip, overnight dialysis was provided to some patients. While this was going on, clinicians noted that these patients did not develop the dependency on others (nurses, doctors, machines) and tended to be more independent. (Depression on dialysis was and is a big issue; it also affects post-dialysis recovery.) By the time Medicare began funding the End State Renal Disease (ESRD) program, 35% of the patients were afforded home hemodialysis (total dialysis census was 7500).
And, following the law of unintended circumstances, the home dialysis census decayed precipitously. Part of the reason was the proliferation of both for-profit and nonprofit dialysis centers, which garnered federal funding and did not see the need to “farm out” the treatment. Part of the reason was Medicare’s bias against payment for home hemodialysis; it only wanted to provide some $20 more for training home dialysis patients (and for a limited time), which was/is insufficient for the effort. [About a decade later, in the early 1980’s, a new company Home Intensive Care (HIC) was formed by Dr. Allan Jacob; its premise was to provide technician- and/or nurse-assisted home hemodialysis, as opposed to in-center dialysis. HIC prevailed until HCFA cut its reimbursement rate dramatically, and was soon merged into National Medicare Care (Fresenius, now)].
Another coincident occurrence (with the advent of Medicare’s paying for ESRD) was the dramatic shortening of the dialysis period- down to about 4 hours. Urea was considered the prime marker for treatment and, with the introduction of more permeable and higher efficiency dialyzers, it was determined that the treatment goal should be to achieve a kt/V of 1.2 or greater (k being the clearance of urea, t the time on dialysis, and V approximately the volume of water within the patient’s body). [Longer hemodialysis periods were not found to reduce hospitalization rates or patient death rates.]
Current research demonstrates that both short and long duration daily home hemodialysis may have some benefit (in addition to the depression issue above, the sawtooth pattern for patient chemistry, cardiovascular and hematological effects). As such, new devices that would improve home dialysis provisioning are being developed. [The first complete commercial device, Aksys PHD, was developed by a team led by an old friend, Rod Kenley, but failed after it could not acquire additional funding. Fresenius just acquired a more modern version of the SorbSystem (Organon/Akzo) that was developed by Dr. Stephen Ash (another long-time dialysis developer); this device diminishes the water treatment requirements for the home. Nx Stage System One is a luggable (I stopped calling my Osborne Computer, all 28 pounds of it, portable decades ago, too) 70 pound unit.] Hopefully, with the advent of the new payment system (to be discussed soon), home hemodialysis will garner more users (it is currently less than 1% of the total patient census) and patients will accrue clinical benefits.