Dialysis Modality Decisions: Choosing Wisely!

Related Article, p. 785 Related Article, p. 785 During the past decade, the number of patients with kidney failure with replacement therapy has increased dramatically.1Thurlow J.S. Joshi M. Yan G. et al.Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy.Am J Nephrol. 2021; 52: 98-107Crossref PubMed Scopus (43) Google Scholar As the benefits and disadvantages of different dialysis modalities continue to be debated, clinical guidelines have adopted the notion of individualization of dialysis facilitated by shared decision making among physicians, patients, and caregivers.2Chan C.T. Blankestijn P.J. Dember L.M. et al.Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.Kidney Int. 2019; 96: 37-47Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar However, there remains an important gap of knowledge as we strive to understand how patients choose their dialysis modality. In this issue of AJKD, Fotheringham et al3Fotheringham J. Vilar E. Bansal T. et al.Patient preferences for longer or more frequent in-center hemodialysis regimens: a multicenter discrete choice study.Am J Kidney Dis. 2022; 79: 785-795Abstract Full Text Full Text PDF Scopus (1) Google Scholar report the results of a discrete choice experiment in prevalent dialysis patients. The authors examined preferences between longer session length (within a 3-times-a-week dialysis schedule) versus 4-times-a-week hemodialysis (HD), or remaining on the standard thrice-weekly dialysis regimen. Among 183 prevalent dialysis patients, 38.3% chose to remain on their present dialysis schedule. However, when given relevant information, 27.1% would choose longer dialysis sessions and 34.3% would pick 4 hours 4 times per week. Factors favoring more intensive dialysis included better quality of life, longer survival, and reduced fluid restriction, while increased vascular access complications reduced the likelihood of a regimen’s selection. Hospitalization had no influence on regimen choice. Patients under 50 years old preferred more intensive regimens, and valued survival advantage and less fluid restrictions. This study highlights the infrequently studied issue of determinants of patients’ choice of dialysis modality. Of note, the study population consisted of prevalent dialysis patients with a mean dialysis vintage of 4.7 years, while previous studies in the field mostly included patients with chronic kidney disease (CKD) not receiving kidney replacement therapy.4Walker R.C. Morton R.L. Palmer S.C. Marshall M.R. Tong A. Howard K. A discrete choice study of patient preferences for dialysis modalities.Clin J Am Soc Nephrol. 2018; 13: 100-108Crossref PubMed Scopus (30) Google Scholar,5Morton R.L. Snelling P. Webster A.C. et al.Dialysis modality preference of patients with CKD and family caregivers: a discrete-choice study.Am J Kidney Dis. 2012; 60: 102-111Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar The patients’ experience with 3-times-a-week HD will no doubt bias their choice of dialysis dosing. Another bias may result from the overly optimistic assessment of survival, which may lead patients to attribute more importance to this outcome than expected. While kidney transplantation is the gold standard of kidney replacement therapy, the most common such therapy is in-center HD. In 2016, more than 80% of maintenance dialysis patients globally received in-center HD.1Thurlow J.S. Joshi M. Yan G. et al.Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy.Am J Nephrol. 2021; 52: 98-107Crossref PubMed Scopus (43) Google Scholar Exceptions included Hong Kong, the Netherlands, and New Zealand, in which fewer than 30% of kidney failure patients underwent in-center HD. Moreover, in-center HD prescriptions also differed between countries, with Australia/New Zealand, Canada, Germany, and Sweden more likely than other countries to provide thrice-weekly HD sessions of at least 4 hours. At the other extreme, dialysis session lengths were the shortest in the United States. Discrepancies in global dialysis practice and patterns are influenced by local resources, reimbursement policies, infrastructure, and—most prominently—patients’ and nephrologists’ knowledge and awareness.1Thurlow J.S. Joshi M. Yan G. et al.Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy.Am J Nephrol. 2021; 52: 98-107Crossref PubMed Scopus (43) Google Scholar,2Chan C.T. Blankestijn P.J. Dember L.M. et al.Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.Kidney Int. 2019; 96: 37-47Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar Even among resource-rich countries, dialysis prescription patterns differ drastically from those theoretically proposed by the present discrete choice experiment, in which intensive dialysis treatment was selected by a significant proportion of surveyed patients. Likewise, other studies have suggested that patients tend to value the benefits of more intense or home-based therapy when provided the appropriate amount of information. Walker et al4Walker R.C. Morton R.L. Palmer S.C. Marshall M.R. Tong A. Howard K. A discrete choice study of patient preferences for dialysis modalities.Clin J Am Soc Nephrol. 2018; 13: 100-108Crossref PubMed Scopus (30) Google Scholar demonstrated through another discrete choice experiment that CKD patients preferred home-based dialysis over in-center, when longer survival and improved wellbeing were expected. Another study, by Morton et al,5Morton R.L. Snelling P. Webster A.C. et al.Dialysis modality preference of patients with CKD and family caregivers: a discrete-choice study.Am J Kidney Dis. 2012; 60: 102-111Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar presented CKD patients’ and families’ dialysis preferences: 65% and 72%, respectively, preferred home dialysis over conservative treatment, especially knowing that life expectancy may increase. How does one reconcile the differences between the proposed proportions of patients who would accept a more intense form or home-based dialysis versus the reality? Discrete choice experiments are commonly used as a statistical tool to assess individual attributes, preferences, and priorities.6Clark M.D. Determann D. Petrou S. Moro D. de Bekker-Grob E.W. Discrete choice experiments in health economics: a review of the literature.Pharmacoeconomics. 2014; 32: 883-902Crossref PubMed Scopus (412) Google Scholar However, discrete choice experiments only offer a theoretical possibility and the results do not always translate into the actual patient choice. Yet it is encouraging to know that proper knowledge of various dialysis modalities may change the proportion of patients adopting more individually appropriate options other than conventional 3-times-a-week hemodialysis. To this aim, present guidelines have continued to encourage nephrologists and care providers to adopt shared decision-making for the most appropriate goal-directed dialysis with all patients.2Chan C.T. Blankestijn P.J. Dember L.M. et al.Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.Kidney Int. 2019; 96: 37-47Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar,7Elwyn G. Frosch D. Thomson R. et al.Shared decision making: a model for clinical practice.J Gen Intern Med. 2012; 27: 1361-1367Crossref PubMed Scopus (1871) Google Scholar Tragically, far too often patients are defaulted to the path of least resistance, with limited choice to in-center HD. Moving forward, the present results serve as a reminder to all nephrology practitioners that timely, iterative, and effective communication to patients about the pros and cons of all forms of kidney replacement therapy should be a foundational element of nephrology practice.8Heaf J. Heiro M. Petersons A. et al.Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study.Clin Kidney J. 2021; 14: 2064-2074Crossref PubMed Google Scholar Shira Goldman and Christopher T. Chan, MD. None. Dr Chan holds the R. Fraser Elliott Chair in Home Dialysis. He has also consulted for Medtronic Inc, Quanta Inc, and Dialco Inc. He has also received an investigator-initiated research grant from Medtronic Inc. Dr Goldman is supported by the Sinai Health Foundation (with sources from the Israeli Government and the Azrieli Foundation). Received October 15, 2021 in response to an invitation from the journal. Accepted October 26, 2021 after editorial review by an Associate Editor and a Deputy Editor. Patient Preferences for Longer or More Frequent In-Center Hemodialysis Regimens: A Multicenter Discrete Choice StudyAmerican Journal of Kidney DiseasesVol. 79Issue 6PreviewLonger and more frequent hemodialysis sessions are associated with both benefits and harms. However, their relative importance to patients and how they influence acceptability for patients have not been quantified. Full-Text PDF Open Access