Alicia Chang, AP
Rodney Sokoloski used to get up before dawn three times a week and drive two hours from his high desert home to the Los Angeles suburb of Torrance to get hooked up to a dialysis machine. The blood-cleansing treatment was time-consuming and often left him feeling drained even before his workday began. Not anymore.
After four months of shuttling back-and-forth, last year the 61-year-old switched to doing dialysis at home every night while he sleeps. He starts it after dinner, wheeling the dialysis machine — the size of a carry-on suitcase — into the living room where he can watch TV or chat with his wife. "It makes you feel like you're in control of your life," said Sokoloski, whose combination of diabetes and high blood pressure led to kidney disease. Yet only about eight percent of kidney patients do dialysis at home. Many don't know they can. Others are afraid to try it, and a limited number of places around the country offer training and support for home dialysis.
New Medicare payment rules that just went into effect could change that. The changes give dialysis clinics more motivation to control costs and raise the amount centers get to teach do-it-yourself dialysis. As for the patients, Dr. Leslie Spry of the National Kidney Foundation says, once they "experience the difference between home and in-center dialysis most will not return to in-center treatment."
There are two types of dialysis that can be done at home. The older and more widely used method — peritoneal dialysis — uses the lining of the abdomen to clean out waste. Patients pour a fluid into a tube in their belly and drain it out several times a day, or a machine handles that while the patient rests — the approach Sokoloski uses. A second, newer method is home hemodialysis. Blood is drawn through a tube from the arm and pumped through a portable machine where it is cleansed and returned to the body. Patients do this four to seven days a week for about 2-1/2 hours each time.
People who prefer home dialysis say it's more convenient, allowing them to set their own schedules and even travel with their dialysis machine. They also like the idea of cleansing their blood of toxins more often because they feel better and don't need to take as many drugs. Dialysis clinics used to bill Medicare separately for costly medications such as the anti-anemia drug Epogen and often made a profit on it. Under the new payment system, centers get a flat rate for dialysis treatments, and certain lab tests and drugs including Epogen. This bundling may spur the industry to take a closer look at home therapy since people who dialyze in their living rooms tend to take fewer drugs than those in centers, cutting costs, according to the kidney foundation and some doctors.
Slightly higher reimbursement to centers to do home training and to health care providers who tell patients about their choices may also help send more patients home, they say. LeAnne Zumwalt, vice president of DaVita, Inc., which runs 1,600 dialysis clinics, said the company already provides home training to patients who meet the criteria. Zumwalt doesn't think the ranks of home dialysis patients will expand significantly unless Medicare reimburses for more treatments, especially for those on home hemodialysis, which requires more supplies and is costlier to support.
Home dialysis isn't for everyone. It can be scary. People who are frail, squeamish about blood or who don't have family support at home are not good candidates. It requires weeks of intensive training and involves some risk: There's potential for infection and the chance of getting an air bubble into the bloodstream, which could lead to death in rare instances. Patients are trained what to do in such emergencies. Many dialysis centers require that spouses or other family members also get schooled as backups.
Eugene Abbott bypassed in-center dialysis and started home hemodialysis last summer after five weeks of training. It's been a learning curve. Sometimes the machine's alarm goes off and he's had to stay calm and troubleshoot. "It's mind-boggling. There's a lot of things to learn," said the 58-year-old machinist from Lincoln, Nebraska. He now does dialysis at home six days a week for about three hours each session. During college football season, he skips Saturdays so he can go to games.
The outlook is good for the future of home dialysis. Research published last year in the Archives of Internal Medicine found that patients who do it themselves fare as well as those who went to dialysis centers. "The biggest challenge in this country is that most patients don't know they have the choice to dialyze at home," said Dr. Rajnish Mehrotra of Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, who led the study. "Many people would prefer to dialyze at home, but they're afraid."
Nearly a quarter of Mehrotra's patients now do home dialysis — a number that has grown because nurses explain the home dialysis option on a patient's first visit. Lois Lucci was among Mehrotra's patients who chose home dialysis in 2008. Lucci does it while she sleeps so her days are free when she's not working part-time as a nurse. "I can go shopping. I can run errands. I can pretty much do anything except go swimming," said the 53-year-old from Redondo Beach, California. She takes the dialysis machine with her twice a year to visit family on the East Coast.
Sokoloski, who works in the high-performance automotive industry, hopes to travel soon. He recently bought a vintage Chevrolet hot rod and plans to take his dialysis machine and supplies with him on the road to car shows around the country this year. "Some people, when they find out they have kidney failure, just curl up in a ball. That's not me," he said.