Dr Brent W. Miller on Emerging Technologies in Home Dialysis and Strategies to Improve Uptake

Several emerging technologies in home hemodialysis and peritoneal dialysis are being developed to improve vascular access, burnout, and issues that lead to discontinuation, with other efforts required to address uptake issues for patients with kidney disease, said Brent W. Miller, MD, board certified nephrologist and professor of clinical medicine at Indiana University School of Medicine.

Miller spoke during a session at the American Society of Nephrology (ASN) Kidney Week 2022 meeting, titled, “Advancing Technologies in Home Dialysis.”

Transcript

Can you speak on some of the novel and emerging technologies in home dialysis you will be discussing during your session at Kidney Week 2022?

Yes, I'd like to break that answer into 2 parts. We're at the ASN meeting; there's I think 11,000 nephrologists here and we're hearing the whole spectrum of advances in kidney disease. And so yesterday there were several just wonderful talks on home dialysis and dialysis technologies that are coming.

Those talks tended to focus on the moonshots—the implantable kidney, the wearable kidney, and all the technologies that go with that. And we're probably a generation away from that. So, that's not what I'm going to be talking about tomorrow. I'm going to be talking about what is here now, what we can use better, and what is emerging this way. And even so when you look at that it's a long list, probably longer than our interview today. And so I broke it down into several things that really are pressure points for technology in patients.

Number one for home hemodialysis is the vascular access. And so we have several emerging technologies in vascular access to help with patients and I think the one that is most helpful is the point of care ultrasound. And so we will now be able to train patients using a handheld ultrasound device in their cannulation and also be able to monitor problems when they come back to clinic with that, and I think that is going to be a major advance in taking technology that is now portable and affordable into the clinic.

Addressing the problems of both peritoneal dialysis and home hemodialysis burnout. So, if you look at the reasons that are really preventable for home hemodialysis burnout, where patients just give up, it typically is the burnout of the machine. So, having smaller, simpler machines with better interfaces to the patients. For a lay audience, if you think about your phone, if we can get there to [do] many of the tasks that your phone automates and you don't have to know computer programming to make it work that's where we need to be.

And you're starting to see that. So, you're starting to see graphical user interfaces in all the machines, you're starting to see the ability of the machines to guide you through the setup process and the alarm process—then you're transmitting data of your treatment back to the clinic so they can look at that if there's a problem, and then also the ability to have real time support, whether that's phone still or whether that's some type of other connection through your machine to help guide you through the treatment.

On peritoneal dialysis, it's a different type of issue with why patients fail—50% of our patients on peritoneal dialysis go off peritoneal dialysis every year. There are 4 or 5 leading reasons and they're different than hemodialysis. It's not the burden of therapy per se, it’s problems with clearance, it’s problems with ultrafiltration, it’s problems with infection. And we are addressing all those with various technologies that I'll get into.

Then we have things that are not available this year, or probably next year, but are in the medium term. And those are on-demand hemodialysis fluids and peritoneal dialysis fluids that can be individualized for the patients, and those will be a big advance. And then there is some monitoring of the dialysis fluids, whether it's peritoneal dialysis or hemodialysis, that can be utilized to guide therapy or to diagnose things like infection. So, lots of things are going on that will be introduced to home hemodialysis and peritoneal dialysis.

With home dialysis still underutilized in the US, what potential for growth do you see here and what initiatives can help drive uptake?

People who have kidney failure are a very, very diverse group of people in terms of the biomedical issues. We have everything from infants, to people who are in their 90s. We have people who have many, many comorbid illnesses and we have people that are relatively healthy that it just affects your kidney. So, it's not one group of people.

And because of that, I'm not sure that with today's technology or even near-term technology we can say 100% of people can do home dialysis. So, if when I take a look at it, where should we be? Well, roughly 30% of our patients are on a transplant list or in evaluation for a transplant. So, that means they're pretty reasonably healthy and reasonably involved in their health care. And there's an estimate that 50% to 60% of people could be on a transplant list.

So, in my mind, if you are engaged in your health care enough and can handle a kidney transplant, you probably can handle home dialysis. So, really, instead of being 15%, where we're at now, 30% is where we should be. So, the question is, why are 30% of people not on home dialysis?

That's a very difficult question to answer, and I think one is we have to recover from the COVID-19 pandemic. We've heard some at this meeting, but [what] you don't hear a lot about is how the pandemic and all the downstream effects of it have affected the ability to deliver health care. And perhaps that's most acute in, I call this a niche business, where 15% of roughly 500,000 people in the whole country are on dialysis.

Delivering that, we need to rebuild our workflows and our staff, and get back to where we were in 2019. And so we're digging ourselves out of a hole in that. So, that's one thing is like, we have to get back to a workflow that really delivers what patients need on home dialysis.

And then you get into some of the other peripheral issues other than technology, which is, and you're hearing about that this week, are we training our physicians as well in home dialysis as we do in in-center hemodialysis, acute kidney injury, glomerulonephritis, critical care nephrology, and kidney transplant?

And I think if you'd asked me that question 5 years ago, I would have said no. If you asked me that question today, I think we're doing better. And there does seem to be a commitment that home dialysis training for all nephrologists, many nephrology nurses, and nurse practitioners is, at least on a policy basis, considered equal. And then hopefully in a few years, the results will be that it is equal. So, I think that's a key part, if you train people better to take care of the patients in home dialysis, you'll see a better product.