Chapter 16: Remote Monitoring and Home Hemodialysis

INTRODUCTION

Patients with end-stage kidney disease (ESKD) undergoing home hemodialysis (HHD) make up only a small fraction of all patients receiving renal replacement therapy (RRT) in the United States. According to the United States Renal Data System (USRDS), there were 106,915 incident in-center hemodialysis (HD) patients (88.5% of all incident dialysis patients) compared to only 488 HHD patients (0.4%) in 2017.¹ Among prevalent patients at the end of 2017, there were 458,125 in-center HD patients (87.5%) and only 9460 HHD patients (1.8%), with the remainder of ESKD patients utilizing peritoneal dialysis (PD) or undergoing renal transplant.¹ Given the low utilization of HHD, there has been significant interest in identifying the barriers that preclude greater use of this treatment modality. Some of the most prominent factors include patient and/or care partner misconceptions about level of difficulty, lack of confidence in performing HHD, concerns about troubleshooting issues that arise during home therapy, and feelings of isolation from medical providers.² However, the overall risks to patients undergoing HHD are very low, with one study citing a procedure-related adverse event rate of 0.06 per 1000 HHD treatments, and overall death rate of 0.0085 per 1000 treatments.³

In August 2017, the NxStage System One dialysis device was approved by the United States Food and Drug Administration (FDA) for solo HHD during a patient's waking hours.⁴ This expanded access to HHD to patients who wish to dialyze without a care partner. Currently, there is no published data on the safety and efficacy of solo HHD. In an analysis of 117,000 HHD treatments, Wong and colleagues examined seven reported adverse events. They noted that five of the seven reported adverse events were related to human error and poor protocol adherence, and two of those seven patients had been dialyzing alone at the time of the incident. For patients undergoing HHD, whether with a care partner or solo, having remote access to a healthcare provider may help alleviate concerns about having to manage problems that arise on their own.³ Telemedicine offers services specifically designed to assist patients, care partners, and their medical dialysis team to address these concerns.

The American Telemedicine Association defines telemedicine as “the use of medical information exchanged from one site to another via electronic communication to improve patients’ health status.”⁵ Telehealth refers to a broader range of health-related services such as education, remote monitoring, and provider-to-provider consultation, in addition to patient care. Telehealth can occur via several modalities, which include real-time telemedicine, store-and-forward telemedicine, remote patient monitoring (RPM), and the use of mobile health services supported by mobile communication devices, such as wireless patient monitoring devices, smartphones, personal digital assistants, and tablet computers. For real-time telemedicine, the patient and/or surrogate interacts with the healthcare provider through audiovisual technology. Store-and-forward telemedicine involves the electronic transmission of recorded medical information through secure portals. Finally, RPM collects a patient's medical data then transmits it to a ...