(by Fulvio Oscar Benussi, publicist and AIDR partner) In these days of pandemic danger, a specific problem has emerged for those suffering from chronic renal failure: the problem of not being able to stay at home because forced to go, accompanied by transport personnel, to carry out regular dialysis treatments in the hospitals or in the Limited Assistance Centers of their Municipality of residence. Each single therapy usually lasts for three to four hours in a row and is carried out three times a week in rooms where dialysis therapy also carries out numerous other patients.
On the other hand, for many of the patients suffering from renal insufficiency, a solution to this problem could have been offered, which would have allowed greater serenity and the possibility of significantly reducing the very high risks of contagion due to the high number of people with whom it is necessary get in touch to carry out hospital dialysis treatments.
In fact, many patients have not suffered from this problem because they carry out peritoneal dialysis. However, this method of performing dialysis therapy is not a solution for everyone. It is not, in fact, practicable for those who, for previous abdominal surgery, do not meet the requirements to be able to practice it.
An alternative to peritoneal dialysis is offered by home extracorporeal hemodialysis methodology.
Although technological innovation has for some years made available innovative digital machines that allow dialysis to be carried out at home easily and without modifications to the domestic electrical and hydraulic system, this therapeutic method has not spread. Why?
On the basis of the testimonies collected by patients and by the posts of the Facebook group "Home Hemodialysis: this unknown!" (Https://www.facebook.com/groups/179655329766113). lack of information on this type of therapy.
Advantages of home extracorporeal hemodialysis, social and personal advantages
Among the social advantages that the dialysis device in your apartment allows you to facilitate, making it more flexible, the management of time to be dedicated to work and that to be dedicated to therapy. With regard to the quality of personal life, the possibility of carrying out home dialysis even on the go is not irrelevant: during the summer holidays or for trips of even shorter duration.
The benefits for patient health
The advantages relating to quality of life must be combined with the advantages in terms of overall health improvement in patients who practice it.
In this regard, in the research coordinated by Dr. Chiara Brunati published in 2017 and relating to 12 patients of the Niguarda Ca 'Granda Hospital in Milan, the results were as follows. In 10 out of 12 patients with the transition to NxStage, the device used for home hemodialysis, there was a reduction in the antihypertensive drugs taken. There has been an improvement reported by all patients, except in one case, of the general sense of well-being. There was a marked improvement in the ability to recover usual activities after the dialysis session. Ten out of 12 patients with home hemodialysis had an increased sense of appetite. "
I point out that the nephrology department of the Niguarda Ca'Granda hospital is one of the Italian centers that over the years have followed a significant number of patients in home extracorporeal hemodialysis
An international research published in 2016 (https://academic.oup.com/ndt/article/31/suppl_1/i294/2224684) which involved 127 patients out of 7 centers in 4 European countries (UK, France, Italy and Spain ) found that brief and frequent hemodialysis performed at home using the NxStage® One ™ system has proven to be an excellent therapy for this patient population, prepared with short hospital training (an average of 17 meetings), giving good biochemical results and reduction of the therapeutic load.
The economic advantages
Finally, it should be noted that various studies have shown that home extracorporeal hemodialysis is significantly less expensive than hospital dialysis and, although to a lesser extent, it is less expensive than dialysis performed in CAL (Limited Assistance Centers).
Data on the costs and effectiveness of the main dialysis treatments can be found in the Resolution of the Piedmont Regional Council -8-12316-of-12.10.2009; pag. 14 and ss. (Http://www.nefropiemonte.info/Normative/Docs/01e%20Contrib%20x%20dial%20domic%20DGR%208-12316%20del%2012ott09%20global%20con%20allegati.pdf) and also in the 'Article "History of home hemodialysis and its probable rebirth": [...] One aspect to be considered separately is the economic one, since dialysis is one of the most expensive life-saving treatments. [...] In the Tuscany Region, the reimbursement offered for home hemodialysis in bicarbonate (€ 125) corresponds to 60% of the same treatment in the Center (€ 208) and 75% of that in the Limited Assistance Centers (€ 155). (Https://www.researchgate.net/publication/305720000_Storia_dell'emodialisi_domiciliare_e_della_sua_probabile_rinascita)
Given the savings that home dialysis allows ASTs, the Piedmont Region has decided that: [...] As regards home hemodialysis, the "Economic contribution" is aimed at the remuneration of the caregiver (Family member), who actively participates in the treatment of the patient according to a fixed contribution of € 250,00 per month.
Little is said about home extracorporeal hemodialysis and its existence is not informed.
Patients with chronic renal failure will probably never have heard of it, as usually, those who suffer from this disease are offered only hospital therapy or alternatively peritoneal dialysis.
Given the social, health and economic findings, the motivation for such a scarce diffusion of this method is incomprehensible. In particular, it is not clear why the previous spending review interventions did not focus on strengthening and spreading home extracorporeal hemodialysis as a possible treatment path for patients who need regular dialysis therapy.
We report the document of the Ministry of Health "National Chronicity Plan, Agreement between the State, the Regions and the Autonomous Provinces of Trento and Bolzano of 15 September 2016" http://www.salute.gov.it/imgs/C_17_pubblicazioni_2584_alached.pdf that, on page 16, in the paragraph Home care, indicates: “The fundamental objective of chronic care systems is to keep the sick person at home as much as possible and to prevent or in any case reduce the risk of institutionalization, without leaving the whole burden on the family assistance to the patient. "
If over the years this objective had really been pursued, today we would face an extremely reduced risk of contagion for those patients who had switched to home dialysis.
However, there is finally good news
On April 22, the Ministry of Health issued the circular, addressed to the regional and provincial councilors of Trento and Bolzano, concerning: "COVID-19 prevention: implementation of home and peritoneal dialysis for patients currently on extracorporeal hemodialysis". In the circular, the Ministry's General Director of Health Prevention underlines [...] the importance, for the patient's well-being, of home and peritoneal hemodialysis and invites the Assessors [...] to increase the use of home and peritoneal hemodialysis, following a path of therapeutic education.
In dark blue the regions with more centers in light blue, more lightly the regions with a smaller number of centers where it is possible to perform home extracorporeal hemodialysis, in gray the regions that have not responded to the request for generalized civic access.
Indications for patients interested in moving to home extracorporeal dialysis
As soon as this emergency phase passes, it will be possible for the affected patients to evaluate the possibility of choosing home extracorporeal hemodialysis.
Here are some indications in this regard that we obtained from the Regions and the Provinces that responded to our request for generalized civic access.
In Emilia Romagna It is possible to do extracorporeal hemodialysis at home in all hospital centers in the region. There are currently 10 patients undergoing extracorporeal hemodialysis at the Policlinico di Modena, at the Saliceto Hospital in Piacenza.
In Lazio region It is possible to do extracorporeal hemodialysis at home at: Giovan Battista Grassi hospital, Columbus - Gemelli hospital, Congiugi Bernardini hospital, San Giuseppe hospital, Anzio Nettuno hospital, Pontecorvo health house, San Giovanni Evangelista hospital. Home extracorporeal hemodialysis patients are 12
In the area Marche the centers that follow the 12 patients in extracorporeal home hemodialysis are: Urbino, Fabriano, Tolentino, Jesi, S. Benedetto del Tronto, University-Hospital "Ospedali Riuniti" of Ancona
In Piemonte they have about 30 home extracorporeal hemodialysis patients: AOU Novara, AOU CSS-Molinette, AO Cuneo, AO Alessandria, TO ”-SG Bosco (17 patients), CN2-Alba, TO1-Martini, TO5-Chieri, AOU Orbassano
In the province of Bolzano, home extracorporeal hemodialysis: 3 patients in Bolzano, 1 patient in Merano and 1 patient in Brunico
In Valle d'Aosta they intend to reactivate the possibility of doing extracorporeal hemodialysis at home at the complex nephrology facility of the USL company.
In Liguria they do extracorporeal hemodialysis at home at the ASL 5.
In Lombardy, the division of the ASST where the service is performed is: ASST Grande Ospedale Metropolitano Niguarda 16 patients; Monza ASST 7 patients; ASST of Valtellina and upper Lario 6 patients; ASST of Bergamo WEST 5 patients; Cremona ASST 4 patients; ASST Saints Paul and Charles 3 patients; Garda ASST 2 patients; Pavia ASST 2 patients; Seven Lakes ASST 2 patients; Lecco ASST 1 patient; ASST Lariana 1 patient; ASST Pope John XXIII 1 patient; ASST of the Civil Hospitals of Brescia 1 patient.