Going for dialysis is an exhausting ordeal. Besides the fear and uncertainty of entrusting your health completely to a machine, patients on haemodialysis often need it about three times a week, with each session lasting up to four hours. Indeed, kidney dialysis is not only a life-saving procedure, but a life-changing one as well.

However, as haemodialysis is extremely resource-dependent, different forms of home-based dialysis methods such as continuous ambulatory peritoneal dialysis (CAPD) were introduced. In contrast to haemodialysis which filters blood, peritoneal dialysis involves leaving specially formulated fluids in the abdomen (inserted via an indwelling catheter) for hours at a time as a means to remove bodily wastes. In this article, we examine the feasibility of home-based dialysis methods as alternatives to haemodialysis.

Canadian health agency claims that CAPD underutilised in patients in developed countries

The Canadian Agency for Drugs and Technologies in Health (CADTH) expert review panel has recently released a report recommending for more patients with end-stage kidney disease to consider home-based dialysis methods1.

"The evidence tells us that in-centre and home-based dialysis offer similar benefits in terms of clinical outcomes," comments Dr Brian O’Rourke, President and CEO of CADTH1.

While one may think that home-based dialysis methods carry higher risks of infection and complications, the report found no differences in health-related quality of life or patient survival rates between both types of dialysis1.

This is reflected in a separate study that found that patients on haemodialysis were twice as likely to be hospitalised in the first year of beginning therapy compared to those on peritoneal dialysis2.

Furthermore, home dialysis methods come at a much lower cost compared to centre-based haemodialysis. For example, a study in India estimates that the monthly cost of home-dialysis is equivalent to just three haemodialysis sessions3. In the United States, patients stand to save more than USD43,000 a year on peritoneal dialysis2.

Respite nurse at Active Global Sangeeta Kaur demonstrating steps in the continuous ambulatory peritoneal dialysis process. Photo credit: Active Global/The Straits Times
Respite nurse at Active Global Sangeeta Kaur demonstrating steps in the continuous ambulatory peritoneal dialysis process. Photo credit: Active Global/The Straits Times

Patients on haemodialysis tend to be more suicidal and have more sleep problems

What do patients think? Although home-based dialysis methods appear convenient, it still requires them to change their dialysate fluids about four to five times a day. Interestingly, studies have shown that patients on peritoneal dialysis may in fact be happier than those on haemodialysis4.

Patients on home-based methods felt that they had more control over their treatment, increased flexibility and less restricted social lives. On the other hand, those on haemodialysis tended to be more depressed, due to poor carer-patient relationships at the centre, difficult access (especially patients living in rural areas) and long waiting times4.

"We know that patients and caregivers place a high value on treatment options that are least disruptive to their daily lives," comments Dr Manish Sood, a nephrologist co-author of the CADTH review1.

"For many patients, home dialysis is a safe and preferred alternative to frequent hospital visits and I'm hopeful that, with these evidence-informed recommendations from CADTH, we can kick-start a national conversation about the role of home-based treatment in Canada," he adds1.

Global trends appear to favour peritoneal dialysis over haemodialysis

While Canada has its eye on increasing patients undergoing home-based dialysis, where does Asia stand? Current data estimates that about 218 patients per million in Asia receive peritoneal dialysis. This number is thought to double by 2030. Asia displays the largest variation of peritoneal dialysis users, ranging from 3% in Japan to 73% in Hong Kong5.

Recognising the advantages CAPD offers to patients – as an alternative to hospital or home haemodialysis – Deputy Health Minister Datuk Seri Dr Hilmi Yahaya said CAPD can bring down the annual treatment bill to RM25,000 per patient, compared to RM40,000 for treatment in the dialysis centres. Nevertheless, the Malaysian government would continue to create more dialysis centres throughout the country to accommodate the rising number of kidney patients, asserted Dr Hilmi8.

Trends in the prevalence of patients on peritoneal dialysis in Asia between 1999 and 2013. Source: Nature Reviews Nephrology
Trends in the prevalence of patients on peritoneal dialysis in Asia between 1999 and 2013. Source: Nature Reviews Nephrology

Indeed, home-based dialysis methods can be quite tedious. Good patient training, understanding and compliance are crucial for these methods to work. Alas, these components depend strongly on sociodemographic factors and basic medical standards of each region5.

Nevertheless, approximately 11% of the global dialysis population currently receive peritoneal dialysis, with usage at a growth rate of 8% a year (higher than that of haemodialysis)5. Coupled with advancements in healthcare, home-based dialysis methods look set on rivalling haemodialysis in the near future. MIMS

Read more:
Singapore's rising kidney failure rates raise concerns over crowded dialysis centres
The state of kidney disease in the Philippines: Preventable, treatable, but lacking in donors
Malaysian university aims to produce cost-effective haemodialysers by 2019

Sources:
1. http://www.newswire.ca/news-releases/cadth-expert-panel-recommends-home-based-dialysis-in-patients-with-end-stage-kidney-disease-656169063.html
2. https://www.ncbi.nlm.nih.gov/pubmed/19670954
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263061/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138410/
5. https://www.nature.com/articles/nrneph.2016.181
6. https://www.nephrologynews.com/making-the-case-for-in-center-self-care-hemodialysis/
7. http://www.straitstimes.com/singapore/health/taking-charge-in-the-home-dialysis-process?login=true
8. https://www.nst.com.my/news/nation/2017/10/295017/dr-hilmi-suggests-capd-home-dialysis-kidney-patients-rural-areas
9. https://www.hindawi.com/journals/ijn/2017/5819629/