New York Times Article on Peritoneal Dialysis

Barbara Boyle had her doubts about trying home dialysis. She had assumed that like most other Americans who need treatment for advancing kidney disease, she’d go to a dialysis center and let the pros handle everything. But the more she thought about the active way she lived, the more she talked to physicians and other patients, the more sense it made to try peritoneal dialysis at home. Barbara Boyle receiving dialysis at her home in Hayward, Calif. Ms. Boyle, 79, and her husband, Les, 70, travel to Europe two or three times a year. A portable system, she said, means that when she’s in Germany or Croatia, “you don’t have to worry about, ‘Where can I find a good dialysis center?’” And at home in Hayward, Calif., she wanted her days free to visit with her grandchildren or go shopping with her sister, instead of spending the typical four hours at a center three times a week. So after she and Mr. Boyle learned the process — it took several days — she underwent two small operations. A flexible abdominal catheter was inserted “west of my hipbone,” she said, then reinserted in a more comfortable position. Now, gloved and masked to prevent infection, her husband helps instill a fresh bag of dialysate (it contains saline, minerals, glucose and electrolytes) and drain the waste fluid three times a day. Each exchange requires about half an hour, time Ms. Boyle spends reading or chatting on the phone. The final evening dialysis continues as she sleeps. Having passed her first anniversary, “I’m a satisfied customer,” Ms. Boyle said. “I have a lot more flexibility” with home dialysis. We can expect to hear more about this option in coming months. More than 400,000 Americans receive dialysis, about half of them over age 65. More than 90 percent go to dialysis centers, which became a growth industry during the 1980s and ’90s, thanks in part to Medicare policies that allowed centers to charge higher fees. But last year Medicare changed its incentives (virtually all dialysis is covered by Medicare, regardless of a patient’s age), and now peritoneal dialysis at home is gaining a little ground. The fledgling Alliance for Home Dialysis — formed by advocacy groups, pharmaceutical firms, dialysis centers and medical associations — wants to encourage that trendlet, because peritoneal dialysis at home is easier to learn and costs less than treatment at a center. “It sounds so complicated and intimidating,” said Dr. Manjula Tamura, a Stanford University researcher and Ms. Boyle’s nephrologist. “But when you sit down with patients and show them what’s involved, they’re surprised at how simple it is.” A pause for definitions: Hemodialysis, which filters the blood of people whose failing kidneys can no longer perform that function, requires an external device to remove toxins. The most common form of dialysis in the United States, it can be done at home but rarely is, because it requires more equipment and the training is more complicated. In peritoneal dialysis, much more common in other countries than here, patients instill fluids and remove waste fluid through an abdominal membrane, with results that are comparable to hemodialysis in a center. (A report from the National Summit on Home Dialysis Policy this spring gives much more information. The National Kidney Foundation is also a good resource.) Neither variety can cure kidney disease — that requires a transplant — but dialysis has given hundreds of thousands of Americans years of additional life. In theory, patients and doctors should weigh the benefits of each kind of dialysis before making a choice. In practice, though, patients’ fears and denial, combined with doctors’ reluctance to deliver unhappy news, means that “patients aren’t being engaged early enough,” said Dr. Allan Collins, who heads a registry called the United States Renal Data System Coordinating Center. Unless patients plan before kidney failure strikes, Dr. Collins explained, “there’s a crisis, and that pushes you into in-center dialysis, which is the fastest treatment you can implement.” For people in their 80s or 90s with renal failure, a growing group, the question of whether to start dialysis — in any setting — grows still more complex. Mortality rates rise: In a 2007 study, Dr. Tamura and her colleagues found that 46 percent of octogenarians and nonagenarians died within a year of starting dialysis. Among nursing home residents of any age, most die within a year of beginning dialysis and only one in eight maintain the same functional ability as before. So in very elderly people with multiple illnesses, dialysis may prolong life, “but it may be months, not years,” Dr. Tamura said. “And they may not feel better during that time. They may spend a significant amount of time in the hospital. That’s part of what makes this a difficult decision.” Even for satisfied customers, dialysis requires adjustments and tolerance. “I just don’t have the energy I used to have,” said Ms. Boyle. “It kind of slows you down.” She sees Dr. Tamura every four to six weeks for blood and urine tests; she also complains about having gained 20 pounds. Over time, a significant number of peritoneal dialysis patients switch to in-center treatment, either because they tire of dialyzing on their own or because the abdominal membrane becomes inadequate to the task. But Ms. Boyle is planning to visit relatives in Italy next year, carrying enough supplies for a few days and shipping the rest ahead. “I’d prefer not to do dialysis at all,” she said. “But as long as I have to, this is how I want to do it.”