Stage V Chronic Kidney Disease: A plea for Home Dialysis

Abstract

Summary

Overall, home dialysis remains underutilized in much of the world. It is only in some parts of the world, such as Hong Kong, Mexico, Thailand, the Netherlands, Finland, Denmark, Iceland, Australia, Canada and New Zealand, that home dialysis is used for more than 20% of the dialysis population. It is observed that in most high- and middle-income countries, home dialysis is generally more economical than center-based dialysis.

According to the results of the REIN 2020 registry, the share of out-of-center dialysis in France has been increasing since 2012. This is mainly due to the increase in the number of patients treated in low medicalized dialysis units (LMDUs) (+7.3% per year between 2012 and 2016, then +3.8% between 2016 and 2020). In contrast, the proportion of patients treated at home has changed little. The percentage of patients on peritoneal dialysis is decreasing (-1.8% per year). Home hemodiaysis is increasing (+10.3% per year) but remains very marginal (1% of dialysis patients). Finally, the advanced age of dialysis patients, which is constantly increasing, cannot be ignored. The proportion of these very old patients has increased from 10.5% in 2012 to 12.5% in 2020. However, during the COVID-19 epidemic, several articles in the literature have demonstrated the protective effect of home dialysis in all its forms (peritoneal dialysis and home hemodialysis) against SARS-CoV-2 infection.

We report on the status of home dialysis in France, its advantages and proposals for its development, as presented at the Home Dialysis Day (DIADOM) of University Seminars of Nephrology (SUN) in Paris in January 2022.

Introduction

Over the past 30 years, the number of dialysis patients has increased dramatically worldwide. In 2010, the number of dialysis patients was over 2 million, and modeling data suggests that the number will more than double by 2030[1]. Several factors have contributed to this increase: improved survival in the general population, reduced mortality in dialysis patients, increased incidence of chronic kidney disease, expanded eligibility criteria for renal replacement therapies, and better access to chronic dialysis in low- and middle-income countries[2]. Finally, since home dialysis (DAH) has been associated with a lower cost than in-center dialysis, better socio-professional quality of life and lower mortality, several centers have opted for DAH as first-line treatment. Overall, the DAH remains very underutilized. Its use is limited to certain regions, such as Hong Kong, Thailand, Mexico, Canada (20%), Holland, Iceland, Finland, Denmark, Australia (29%) and New Zealand (52%)[2];[3]. The prevalence of home hemodialysis (HHD) in New Zealand, Australia, Denmark, Finland, Sweden, the Netherlands, and the United Kingdom is 15.6%, 9.4%, 4.6%, 4%, 2.8%, 2.4% and 2.1%, respectively[4]. In recent years, many scholarly organizations worldwide that study kidney disease have mobilized in favor of a change in policies and practices in order to increase the accessibility and adoption of DAH[2]. In France, chronic renal failure is a major public health problem, affecting nearly 3 million patients. At the so-called terminal stage of chronic kidney disease (CKD), which affects more than 83,000 patients, renal function replacement therapy becomes necessary. If approximately 40,000 patients benefit from a kidney transplant, nearly 50,000 patients are treated by dialysis[5]. In France, according to data from the REIN registry, 93% of these patients are treated by the hemodialysis technique in care units (either in dialysis centers or in low medicalized dialysis units (LMDUs)) or by self-dialysis[6]. There is an alternative to hemodialysis in a center or LMDU: home dialysis. It can currently be carried out according to two treatment methods: peritoneal dialysis (PD) and home hemodialysis (HHD).

Widely adopted in many countries around the world, where 20% of dialysis patients suffer from end-stage CKD[4];[7], home dialysis is struggling to progress in France, and is currently used for only 7% of dialysis patients (6% in PD and 1% in HHD)[6]. Unfortunately, DAH which peaked in 2003 at 10.5% (PD: 8.7%, HHD 1.8%)[8], giving some people a glimpse of the possibility of reaching the ambitious figure of 15% of French dialysis patients being able to receive treatment at home in 2010[6], has actually slowly and inexorably declined, and stagnated at the current low levels since 2008[6]. The current national figure, a low of 6% of PD patients, in fact conceals significant regional disparities. However, the desired objective (10 to 15% of patients treated with PD), which we announced in a 2006 editorial published in Nephrology and Therapeutics[9], is far from being achieved. Should we resign ourselves to this situation, or should we ask ourselves the right questions to move forward? The objective of this editorial, advocacy for DAH, is not to convince the nephrology community, but to persuade regional health agencies, political powers and patient associations of the medical and financial benefits of the different modalities of DAH as quality renal replacement therapy.

Home dialysis as the optimal method for remote residential areas.

The network of dialysis centers allowed by the Kouchner law at the end of the 1990s allowed the significant shortage of dialysis stations in France to be overcome. It has not spread to remote residential areas once again popular with younger generations, particularly following confinement during the first wave of COVID-19 and the large-scale implementation of teleworking[10]. It would be regrettable to pursue a policy of setting up new dialysis centers on these new, very large outskirts of towns. For future patients with end-stage renal disease (ESRD) from these remote locations, DAH (in particular HHD and PD) seems the most rational response given their level of education, their involvement in telework, the adequacy of their accommodation and their desire for autonomy. Many will be “ideal” candidates for kidney transplantation (because of their young age). Nevertheless, we can unfortunately fear that with the perpetuation of the COVID-19 pandemic, these patients will at best have a transplant waiting time identical to that in the period preceding this pandemic, and at worst a longer dialysis time due to the deleterious impact of the pandemic on the organization of transplantation in France. This therefore presupposes a high quality of extra-renal purification currently permitted by the various techniques of home dialysis.

Anticipating and ensuring dialysis in old age

The current pandemic has allowed a focus on the extreme fragility of age (with an “early” cut-off threshold at 65), which is a major risk factor for death from this virus and one that is found consistently, across countries. It also revealed an unexpected societal solidarity between generations, expressed by the choice of generalized confinement with heavy economic consequences, while highlighting the deep flaws in the organizations and funding of establishments for dependent elderly people in the different countries of the Organization for Economic Cooperation and Development (OECD)[11]. This pandemic has paradoxically also contributed to raising awareness of the challenges of longevity, giving meaning to the creation of a «fifth risk» provided by

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