portable travel dialysis machine

Traveling While on Dialysis? Start Here.

April 19, 2022, 11:52am EDT

Now that summer is approaching, many of our minds have turned to vacation plans. Whether you imagine relaxing on sandy beaches, tubing on a snow-capped mountain, or taking a tour around a city, here’s how to prepare for traveling while on dialysis. 

Table of Contents

Documentation, hemodialysis and traveling, home hemodialysis and traveling, peritoneal dialysis and traveling.

• Have questions about traveling while on dialysis?

Many people who receive dialysis can travel while continuing their treatments; however, you may have specific requirements not listed in this article. Discuss travel plans with your doctor and follow their guidance. 

Once you have the green light from your care team, here are six ways to prepare for your trip:

• Medications: Make sure you have enough medicine for the entire trip. Keep them in your carry-on, as luggage may get lost, and bring a copy of the prescription with you, just in case.
• Insurance: Check with your health insurance company to see if they cover the cost of dialysis while traveling. 
• COVID-19: Check the CDC travel requirements before traveling .
• Activities: Plan activities according to your abilities and allow for time to rest and recharge.
• Fluid and diet restrictions: Pack or plan to buy healthy and nutritious meals, snacks, and drinks that follow all dietary recommendations from your doctor or kidney nutritionist. 
• Emergencies: Your personal doctor and the doctor at the local dialysis center will create a plan should you need to be admitted to a hospital while you are away from home. 

Learn more .

Your travel-destination dialysis center needs to know as much about you as possible to appropriately care for you. Keep a copy of your records with you at all times and have your home dialysis center also fax your records to the dialysis center you’re visiting:

• the dates you need dialysis treatment
• your name, address, etc.
• medical history and recent physical exam reports
• recent lab results
• recent chest x-ray
• your dialysis prescription and 3 to 5 recent treatment records
• dialysis access type
• special needs or dialysis requirements
• information about your general health
• insurance information
• where you will be staying in the area
• a list of the medications you take during treatment and at home

Speak with your regular dialysis center about your travel arrangements at least 6 to 8 weeks before traveling- longer if your destination is popular. Some centers may help arrange your treatments or provide relevant information and documentation. You or your patient coordinator may need to contact multiple centers to find appropriate appointment times. 

Many people using home hemodialysis make arrangements for in-center treatments when they are traveling; however, it may be possible to continue with home treatment as usual. Check with your dialysis care team to see if you can travel with the machines, supplies, and portable water treatment equipment. Let a center know when you’ll be in the area and see if they can provide medical assistance if needed.

Additionally, most dialysis and equipment companies have toll-free numbers for 24-hour help. Write them down as they may come in handy. 

Traveling with a peritoneal dialysis system is often easier because there’s no need to use standard dialysis units. However, it may still be a good idea to arrange backup medical care.

Continuous ambulatory peritoneal dialysis (CAPD): Bring enough supplies to cover the length of the trip, plus extra supplies as a backup. You may be able to deliver supplies to the destination for extended stays. 

Automatic peritoneal dialysis (APD: If your trip is one week or longer, you can have supplies delivered to your destination. Smaller cycler machines are also available, which are easier to carry on airplanes and use in smaller spaces like campers. 

Have questions about traveling while on dialysis? 

Our Patient Information Help Line, NKF Cares , can help! Call toll-free at 855.NKF.CARES (855.653.2273) or email [email protected] .

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Air Travel with a Portable Dialysis Machine

• by John Morris
• December 26, 2019
• Portable dialysis machines are considered to be medically necessary assistive devices under the Air Carrier Access Act .
• Carriers must permit passengers to stow the portable dialysis machine in the aircraft cabin or, if it is too large, in the cargo hold. There is no baggage charge for medical equipment.
• Equipment necessary for dialysis treatment, including dialysis fluids, must also be carried without charge.
• If a portable dialysis machine is lost or damaged during transport, the airline is responsible for an amount up to the original purchase price on domestic itineraries. The liability limit on international itineraries according to the Montreal Convention is 1,131 Special Drawing Rights (SDR) or about $1,560 USD.
• Portable dialysis machines cannot be used during flight.
• Ask to speak with the airline’s Complaint Resolution Official (CRO), who is supposed to be trained on all ACAA regulations.
• If the airline’s CRO does not resolve the matter, call the Department of Transportation’s disability hotline during normal business hours (9 am to 5 pm Eastern time, Monday through Friday except Federal holidays) at 1-800-778-4838 (voice) or 1-800-455-9880 (TTY).
• File a complaint with the DOT’s Aviation Consumer Protection Division alleging an ACAA violation by following the steps described in this article .

John Morris

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Be Prepared When You Fly with a Dialysis Machine

The law is clear that people traveling on an airplane with a portable dialysis device such as a PD cycler or NxStage hemodialysis machine should not encounter any difficulties. However, problems still happen, so be prepared . The intent of the DOT regulations, Guidance on the Transport of Portable Dialysis Machines by Travelers with Disabilities is to remind airlines of their obligations and inform people with disabilities of their rights regarding the use and transport of portable dialysis machines.

Heading to the AAKP meeting in Las Vegas, I booked a flight from Quincy, IL to St. Louis, MO for travel on Thursday, September 25, 2014 with Cape Air, a commuter airline with small planes. I contacted the corporate office in advance to explain that I would be taking my dialysis machine on the plane. The NxStage machine in its travel case weighs 100lbs, and Cape Air had taken it before. Their representative checked with someone and said, “ Yes it would be ok to take ,” and we discussed the weight and size of the machine and how it would work. The representative contacted the Quincy Airport staff to let them know the machine would be on the flight. They stowed the machine in the back of the cabin and all went well with the flight from Quincy to St. Louis.

Unfortunately, before I headed home on Friday, September 26, 2014, I received a phone call from Cape Air customer service stating that they would not be taking my dialysis machine on my return flight because it did not meet their weight regulations of 70lbs!

I had to leave the meeting to take her call because I was very upset, shaking, and feeling as though my life was being threatened. After some heated discussion I said, “ You cannot leave a disabled women standing in the middle of the St. Louis Airport with a dialysis machine—a treatment I need every day to stay alive—with nowhere to go! ” She said she would get back to me.

Luckily, I had the Disability Hotline number with me . The hotline staff was also upset on my behalf, because an airline cannot change travel arrangements they had already agreed to while a passenger is en route. Within a short time, Cape Air called me and said they would “ make an exception this time ” and take my machine on their return flight because they rearranged some of their inventory, but “ would not be able to do it again .”

When I arrived in St. Louis at the Cape Air ticket counter, the man complained that Cape Air should not be taking my machine and they had to vacate seats for it, etc… He would not take the machine as a checked bag at the ticket counter, as it had been done before. Instead, I had to go through TSA especially for the machine, a TSA manager had to be called, and it turned into a big deal that took 90 minutes. After I got home and shared my story, NxStage, suggested that I file a complaint with the Department of Transportation.

As it turned out, taking the machine on the flight did not even seem to affect Cape Air’s ability to carry a full plane of passengers:

• The flight from Quincy, IL to St. Louis had 6 passengers plus a pilot: 7 people.
• The flight from St. Louis to Quincy, IL had 7 passengers plus 2 pilots: 9 people.
• They stowed my machine in the back of the plane on the floor—and it weighed less than a normal sized adult.

The Air Carrier Access Act (ACAA) of 1990 says that airlines can’t discriminate against people with disabilities on U.S. and foreign flights. The U.S. Dept. of Transportation (DOT) has rules under the ACAA to help people with disabilities travel by air especially those traveling with an assistive device such as a portable dialysis machine.

Some tips for flying with a portable dialysis machine from a Life@Home article on Home Dialysis Central:

• Ask the airline if they have a Disability or Special Assistance Coordinator when booking your flights, and make this person aware of the portable dialysis machine.
• Be prepared and take information with you about traveling with a portable device in case you run into trouble. Many airline staff do not know these regulations and have never seen a portable dialysis machine.
• Call the DOT Disability Hotline at 800-778-4838 (voice) or 800-455-9880 (TTY) if you have problems.
• Measure a PD cycler’s case to see if it will fit in an overhead bin or under the seat. If not, it will need to go as checked baggage.
• The NxStage System One is too large to fit in the airplane cabin and can only go as checked luggage.
• Box up and mail your additional medical supplies ahead of time or pack all supplies and medications in your carry-on. If you do this, it is wise to have a note from your doctor giving you permission to travel with needles, etc…
• Ask the hotel if they will waive the fee for accepting and storing boxes with medical supplies.
• Ask the hotel ahead of time for a bathroom scale. Many have them, so you don’t have to take one with you.
• If you don’t plan on handling the device yourself and will be relying on airline, taxi and hotel personnel to help with it, have cash on hand to tip them. Plan to tip $5-10 for your machine plus $2 per box.
• Hotel personnel can also help with lifting and setting up the machine.

Know your rights when you travel with a portable dialysis machine:

• Airlines are not allowed to charge you for the portable dialysis device as additional baggage.
• They are not allowed to ask you to sign a waiver for loss, damage or liability. If something happens to the machine they are responsible for replacing it.

“US Department of Transportation (DOT) document which was designed to implement the Air Carrier Access Act of 1986. This 16 page document (14 CFR Part 382) outlines “Nondiscrimination on the Basis of Disability in Air Travel”. http://airconsumer.dot.gov/rules/382short.pdf

“Guidance on the Transport of Portable Dialysis Machines by Travelers with Disabilities”. http://www.dot.gov/airconsumer/notice-portable-dialysis-machine

NxStage http://www.nxstage.com/homehemodialysis/products/travel

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Life with Kidney Disease

Travel rights for people on home dialysis.

Adapted from the LifeLines at Home article, “Leaving on a Jet Plane”

The Air Carrier Access Act (ACAA) of 1990 says airlines can’t discriminate against people with disabilities, and that includes people who are on peritoneal dialysis (PD)  or home hemodialysis (HHD) . The law applies to U.S. and foreign flights. The U.S. Dept. of Transportation (DOT) oversees air travel and has rules under the ACAA to help people with disabilities travel by air. These rules, called 14 CFR Part 382,i, cover your rights when you need an “Assistive Device”ii— like a portable dialysis machine.

Your rights include:

• Not counting your dialysis machine as a carry-on item if it fits in the overhead bin or under the seat in front of you on the plane (Section 382.41(d))
• Help with stowing and retrieving your machine as a carry-on item (382.39(b)(5))
• Stowing your machine so it is one of the first things off the plane at the end of the flight, if you checked it as luggage (382.41(f)(2))
• Giving your machine priority over other bags if space is limited (382.41(f)(3))
• Baggage liability limits don’t apply if the airline loses or harms your machine—they must pay for your machine based on the purchase price (382.43(b))
• Not being asked to sign a waiver of liability for loss or damage (382.43(c))

Your rights, when you check a dialysis machine as luggage, are often not well known by agents. Some may try to charge a fee if you have suitcases plus a machine. (NOTE: With high fuel prices, most airlines now charge a fee for checked bags.) Some will charge you if your machine weighs more than 50 lbs. DOT spokesman Bill Mosley says, “We’ve told carriers that they shouldn’t charge for dialysis machines, which are assistive devices.” Under the ACAA(Section 382.57), the airlines are not allowed to charge you for your dialysis machine. iii

Here is the section of the manual that tells the airlines that they can’t charge you: iv

Question: Are airlines allowed to charge for providing services to passengers with disabilities?

Answer: Airlines are not allowed to charge passengers for providing services or accommodations required by Part 382, but may charge for optional services or accommodations. Examples of required services for which carriers may not charge are assistance with enplaning, deplaning, and making flight connections, and the carriage of assistive devices (including the provision of hazardous materials packaging for wheelchair batteries, when appropriate). Examples of optional services for which carriers may charge are the provision of in-flight medical oxygen and stretcher service. (Section 382.57)

Right to bring your dialysis machine on a plane

Before you purchase a ticket, go to the airline’s website to check the carry-on bag limitations. You can use that information to determine if your PD cycler —in its case—will fit on the plane or must go as checked luggage. TheNxStage ® System One used for HHD  is too large to fit in any airplane cabin and can only go as checked luggage

Plan to arrive at the airport two hours early; it takes time to talk to airline agents who don’t know about travel with a dialysis machine.

Right to carry medications and syringes with you

Bags go astray. It doesn’t happen often, but it does happen. To be safe, always pack all medications in your carry-on—never in checked luggage. Airplanes don’t have refrigerators, so if you have a drug that must be kept cold, ask your pharmacist how to package it for travel.

If you bring syringes, you must also bring along the drug you inject, such as insulin or EPO. And that drug must have a professionally printed label that says what it is. There is no limit to how many empty syringes you can bring, as long as you also have the drug with you.

Get help at the security line

If it has been a while since you last flew, you will find that some things have changed, including what you’re allowed to bring on a flight.

Liquids in carry-on bags must be 3 ounces or less in a bottle no bigger than 3.4 ounces. All of these liquids must be carried in a clear, 1-quart zip lock bag. Security will throw out anything larger. There is no limit on the amount of liquids you can pack in your checked luggage. The 3.4-ounce limit does not apply to medications, baby formula or contact lens fluid. For a full list of what is prohibited in carry-on and checked bags, visit the Transportation Security Administration (TSA) website .

At the security line, you’ll put your carry-on bags onto a belt to go through an X-ray machine. Ask for help, if you need it, to lift your cycler onto the belt. Because most airport security guards have never seen a PD cycler, you may have an easier time if you bring the manual for your machine and/or a letter from your doctor to explain what it is.

If your PD catheter has the titanium adapter, or if you have an insulin pump, pacemaker, a steel plate in your body, a prosthetic limb or other hidden medical device, tell the security guard before you go through the metal detector. Most airports will ask you to remove your shoes before going through the metal detector, so wear shoes that are easy to take off. If you set off the metal detector, the security guard will ask you to step aside for a more careful search.

Right to pre-board your PD cycler

As an assistive device, a PD cycler has priority for stowage. Be sure to measure it first so you know it will fit in an overhead bin. If you plan to bring your cycler onto the plane, tell the gate agent and ask for help to get your cycler on board and stowed if you need it. When boarding starts, the agent will ask for passengers who need assistance or extra time getting down the jet way to board.

Traveling with dialysate

If you do PD or use a NxStage machine for HHD, you’ll need to bring dialysate on your trip, too. Plan ahead so your supply company can ship most of the boxes to where you’re staying. Get more detail about planning ahead from the DaVita.com article, Traveling for Home Dialysis Patients . The airlines should also allow you to take a day or two of dialysate without a fee for extra or overweight luggage, but there will be a charge for more than that. All supplies must be in their original boxes, with the contents clearly labeled.

Better travel when you know your rights

Now that you know your rights as a home dialysis patient, travel may be a smoother experience. If you do encounter any problems, you can report it to the DOT Disability Hotline at 1-800-778-4838 (voice) or 1-800-455-9880 (TTY). You can also call DaVita Guest Services for many of your travels needs at 1-800-244-0680.

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Travelling on home haemodialysis

For many of those on dialysis, being able to travel is an important part of maintaining their lifestyle and wellbeing. Fortunately, it is still possible to travel, even if you are receiving home haemodialysis treatment.

Before you start your trip, you will need to take the proper precautions to ensure you have the right treatment plan in place. You’ll also need to work in collaboration with your dialysis healthcare team to help you stay healthy, even while you are away from home.

Preparing to travel while on home dialysis does require some planning on your own and in collaboration with your dialysis healthcare team. Luckily, there are a number of options available to help you stay on top of your treatment. Some of these include:

• Booking a dialysis chair with the Big Red Kidney Bus – the bus travels to a range of holiday park destinations around New South Wales and Victoria throughout the year. Make sure you book at least 2 weeks ahead of time – the bus can get busy during peak holiday season.
• Taking your machine with you – your home dialysis machine can be used anywhere while you travel, whether that be by caravan, trailer or boat.
• Going to a fixed dialysis house or campervan – determine if there is an already available fixed dialysis machine that you can use.
• Organising dialysis at another unit near your destination – if you know your travel destination, contact a dialysis unit close to where you’re staying well in advance so they can accommodate you on the days you require. Visit our Dialysis Unit Guide to find a dialysis unit near you.
• Organising a special holiday tour with dialysis included – there are a number of travel tours available for patients currently undergoing home dialysis treatment.

No matter the travel treatment option you chose, you need to make sure you’ve confirmed your plan with your dialysis healthcare team.

If you have a portable dialysis machine, you can use the machine for your treatment while on the go. With a bit of extra planning and effort, you can enjoy your holiday and stay healthy while travelling.

To use your dialysis machine correctly while travelling you’ll need to follow a few guidelines. Some of these include:

• Making sure you take your machine and dialysate bags with you. If you don’t have any bags with you, ensure they can be delivered to your final destination.
• Checking if your machine needs to be linked to water treatment. If your machine requires water to function, you’ll need to factor this into your travel plan.
• Talking to your dialysis healthcare team. They are an essential part of all your travel plans and are available to support you with technical support and advice.

There’s a lot to explore in our own backyard. If you’re looking to travel locally around Australia, then the Big Red Kidney Bus program can help you to explore and stay on top of your home haemodialysis treatment.

The Bus is available for all dialysis patients, all over Australia. It travels to popular tourist locations throughout regional New South Wales and Victoria. From stunning Torquay to coastal Ballina, the Bus can take you to beautiful coastal and popular tourist destinations throughout these two states.

We’re also expanding the route of the Victorian bus route to include a visit to picturesque Tasmania. If you would like to secure your place on this special Big Red Kidney Bus program starting in 2021, check with us for dates and locations.

If you have any questions about our holiday programs, or would like to make a booking with the Big Red Kidney Bus , please call the Kidney Health Australia Helpline on 1800 454 363.

Big Red Kidney Bus

The Big Red Kidney Bus makes it possible for people on haemodialysis to enjoy a much-needed holiday. Read more about eligibility, locations, dates and how to book your spot on our Big Red Kidney Bus page.

Riding the tide of dialysis

Riding the tide of dialysis shows how you can travel in a caravan equipped with a haemodialysis machine.

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Can New Technology Make Home Dialysis a More Realistic Option?

The Tablo System promises to make dialysis easier and more convenient for patients. But there are significant barriers to the technology.

By Dawn MacKeen

This article is part of Upstart , a series about companies harnessing new science and technology to solve challenges in their industries.

Paul Hall was thinking about his pool. In his mind, he was far from the nondescript clinic in Orange, Calif., where he was sitting quietly, his blood traveling through a hemodialysis machine, clearing it of toxins. Soon, he would be watching his three grandchildren splash around while doing his treatment. Or watching TV. And he would do it all at any hour he pleased.

“There’s no place like home,” Mr. Hall, 64, said.

He had just a few more sessions left to be trained on using the Tablo Hemodialysis System , a home dialysis product made by Outset Medical , based in San Jose. When he was done, he hoped to plug it in at his home in Moreno Valley.

The size of a college-dorm refrigerator, the hemodialysis machines of this generation look nothing like the hulking ones first introduced to the home market in the 1960s. A touch-screen, which uses 3-D animation to walk users through each step, is mounted atop a box with a built-in water purification system.

After a 30-minute setup process, which included inserting two 14-gauge needles into his left arm, the machine commended him, “Good job, Paul!”

Like most of the 780,000 Americans with the end-stage renal disease, Mr. Hall needs dialysis, or a transplant, to live. The number of people with chronic kidney disease in this country is expected only to grow . It already affects about one in seven adults, according to the 2022 annual report of the United States Renal Data System .

A transplant wouldn’t be Mr. Hall’s first; the one from his oldest child about two decades ago is failing. Without working kidneys, extra fluid and toxic waste can build up and poison the body. Each year, about one in six patients undertaking maintenance dialysis dies, according to the U.S.R.D.S. Others forgo the treatment, most likely because of other life-limiting conditions, such as advanced cancer or heart failure.

“Patient outcomes are definitely better, but are still unacceptably poor,” said Dr. Joseph Vassalotti, chief medical officer of the National Kidney Foundation.

The company that would become Outset Medical started in 2010; it launched commercially in 2018, when Tablo entered hospitals and clinics. The Food and Drug Administration cleared Tablo for home use in March 2020, just as vulnerable populations needed to isolate because of the coronavirus pandemic. Later that year, the company went public in a virtual I.P.O .

The only current alternative for home hemodialysis systems is the portable NxStage System One , made by Fresenius Medical Care, which has headquarters in Germany. It was introduced to homes in 2005, with a newer version, VersiHD, following more recently.

Of the hemodialysis units examined in a market analysis, Tablo is the most expensive hemodialysis unit on the market, according to a survey by ECRI, a federally certified nonprofit patient safety organization. Tablo costs an average price of $47,000, excluding service or operational costs, compared with $26,000 for the NxStage System One.

Dialysis is indeed costly. The Centers for Medicare & Medicaid Services is hoping to reduce its expenditures and improve quality of care for its beneficiaries with end-stage kidney disease. Through financial incentives to dialysis providers, physicians, health systems and kidney transplant programs, the agency is seeking to increase home dialysis, as well as kidney donation.

The clear need for home systems is another factor. A majority of dialysis patients travel to clinics for hemodialysis, with little flexibility for long distances, snowstorms or car trouble. Patients often rate themselves as having a low quality of life, as cramps, insomnia, depression and anxiety are all common .

Mr. Hall has missed so many life events, he said. And while he doesn’t complain, when clinics close for long holiday weekends, he notices a difference.

“I can tell how I feel after two days,” Mr. Hall said. “If it’s starting to get harder to breathe and I know there’s fluid on my lungs, I want to get that off of me.”

Home dialysis is not a novel idea, said Leslie Trigg, Outset Medical’s chief executive. In the early 1970s, over 30 percent of dialysis patients were estimated to have done their treatment at home. Often, they had little choice, with dialysis units unable to meet the demand, according to a 2017 review in the journal Seminars in Dialysis.

In 1972, this changed with the expansion of Medicare, which included coverage for people with end stage renal disease in need of dialysis or a kidney transplant; in turn, that funding from coverage allowed for the growth of outpatient dialysis clinics. In the half-century since, the patient population for dialysis has grown, as has for-profit in-center dialysis.

Now about 14 percent of dialysis patients treat at home, either by themselves, or with a care partner, and that number is growing, according to the U.S.R.D.S. An estimated 2 percent are on home hemodialysis. Most do peritoneal dialysis, which involves infusing dialysis solution into the lining of the abdomen to filter the wastes from the body. It is usually prescribed daily, and for significantly longer periods each day than hemodialysis.

Mr. Hall tried this, too, for two years. He preferred peritoneal, and wishes he could be back on it now, but developed an infection.

Training is required for all home dialysis candidates and the person helping them, and the company or home health agency usually visits the home during the initial period.

But even with these measures in place, there are other considerations.

“It’s not for everyone,” said Dr. Mark Sarnak, chief of the nephrology division at Tufts Medical Center. “Some people have needle phobia, some people may not have the eyesight to do peritoneal dialysis, some people may be too sick.”

And not all are comfortable with the technology, have the support of family members (if needed), or the extra room to store the supplies or machine. Others prefer having a trained professional overseeing treatment.

For Mr. Hall to do his three-hour Tablo treatment, he connects one needle to an arterial line to move the blood through the machine’s dialyzer, also known as an artificial kidney. He attaches the other to the venous line, through which his cleaned blood returns. The most challenging part to him, though, is the end of treatment, when he has to remove the needles and apply just the right amount of pressure to avoid significant blood loss. His ex-wife and daughter have trained on how to assist.

There are benefits to the easy access of home dialysis. Traditionally, in a clinic, a lot of fluid is removed within a short period of time, and many patients feel exhausted afterward. With peritoneal dialysis and more frequent hemodialysis, “it’s much gentler,” said Dr. Sarnak, the lead author of a recent statement by the American Heart Association. There are also potential cardiovascular benefits with more frequent hemodialysis, according to the statement.

( Risk of infection , however, may increase with higher frequency. And although uncommon, infection is a risk for peritoneal dialysis patients as well.)

The F.D.A. encourages a care partner while using Tablo — another potential barrier to patients wishing to switch to home use; the clinic overseeing the patient at home confirms the availability of one, according to Outset Medical. (NxStage System One is cleared to be run alone, but if patients use it at night while sleeping, a care partner is encouraged.)

Another issue is that home dialysis has not reached all of the populations in need. Black and Hispanic patients, disproportionately affected by kidney disease, are less likely to begin home dialysis than white patients, according to the U.S.R.D.S.

More options may be on the horizon. One from Quanta Dialysis Technologies, already cleared for chronic and acute settings, is in clinical trials for the home. Another, from CVS and Deka Research & Development Corp., is in the final stages of a clinical study.

At the start of this year, 2,300 of Outset’s systems were being used in hospitals, rehab facilities and long-term care facilities. But the company’s home rollout has been slow, with an estimated 300 devices being used by patients in the home or in training locations, according to the company’s latest public numbers.

The research on Tablo is promising, doctors say, but limited because of its small sample size and relatively short-term follow up. Dr. Michael Aragon, a nephrologist based in Fort Worth, Texas, helped to oversee Tablo’s home safety and efficacy trial before joining the company as chief medical officer. The trial found that 28 patients with end-stage kidney failure who completed the study had adequate removal of toxins on Tablo, and the device was deemed to be safe both at home and in clinic.

During Mr. Hall’s test treatment at the clinic, he also had to learn how to troubleshoot. Two hours in, as the leaves of a tree on the machine progressively turned green to show the time remaining, an alarm sounded. The machine had tried to take his blood pressure but couldn’t. A nurse repositioned the cuff. (Although it’s uncommon, losing consciousness from a drop in blood pressure is a risk at home or in the center.)

Several reports of bleeding, loss of consciousness and deaths associated with the Tablo have been reported to the F.D.A.’s database of adverse events over the past four years. Ms. Trigg said none of the adverse events impacting patients had been adjudicated by the company as Tablo-related.

NxStage System One also has its own share of similar adverse events, though a spokesman for Fresenius Medical Care said that no injuries or deaths have been adjudicated as the fault of the machine’s equipment.

Ismael Cordero, senior project officer for device evaluations at ECRI, the safety organization, reviewed reports from both companies. Any potential hazards, he said, become “even more concerning when the devices are used outside of a clinical setting.”

Carly Kempler, a spokeswoman for the F.D.A. said that the database has limitations, and that “if the F.D.A. becomes aware of information that reveals a safety concern with a medical device, the F.D.A. will take action as appropriate.”

Mr. Hall hopes to be given another transplant. In the meantime, he’s finally treating himself at home, with his family’s help. Though the first Tablo he received had glitches, its replacement is working smoothly.

No longer commuting to the clinic, he’s happy for the choices each day holds — simple ones like, early morning treatment, or evening? “That’s a great feeling of knowing I can work around whatever comes up,” he said.

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• v.13(10); 2021 Oct

Cost-Effectiveness of Home Hemodialysis With Bedside Portable Dialysis Machine "DIMI" in the United Arab Emirates

Chandra mauli jha.

1 Nephrology & Dialysis, Al Mazroui Medical Center, Abu Dhabi, ARE

2 Nephrology, Nephro Care Home Hemodialysis, Abu Dhabi, ARE

Background and objective

The incidence and prevalence of patients requiring renal replacement therapies (RRTs) are increasing worldwide and a large number of these patients die prematurely due to the unavailability of treatment. While in-center hemodialysis remains the most commonly practiced modality globally, more and more patients find it unsuitable due to their frail condition, difficulty in ambulation, and time lost in traveling, etc. Such patients find the self-administered or nurse-assisted home hemodialysis (NAHHD) more suitable. The costly and recurring nature of these therapies prompted us to evaluate and compare the cost-effectiveness aspect of these two treatment modalities. Thus, the aim of the study was to investigate if home hemodialysis (HHD) with a portable hemodialysis machine was cost-effective in comparison to in-center hemodialysis for patients of end-stage renal failure (ESRF) in the United Arab Emirates (UAE). This is the first study of its kind to be conducted in the UAE.

Methodology

The study topic was developed based on an informal inquiry from the health regulator of Abu Dhabi if HHD was cost-effective compared to in-center hemodialysis with an emphasis on a portable dialysis machine. No such head-to-head study performed in the UAE was available. Hence, a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) design was chosen as the investigative method. An outline of the study was drafted, and a literature search of Science of Web, PubMed, and Cochrane Evidence was performed using the keywords "Home Hemodialysis", "home-based Dialysis", "Cost-effectiveness of Dialysis", "Cost-effectiveness of renal replacement therapy", etc. A review of the article titles was performed to include the articles relevant to the cost of RRTs and the economic burden of ESRF. Full text and abstracts of those articles were retrieved, studied, and, the articles that were found not relevant were excluded. The remaining articles were studied and used in the evidence synthesis. DIMI was chosen to represent a standard type of recently developed portable dialysis machines.

It was interesting to find out during the review that HHD and in-center hemodialysis had been developed simultaneously but the former had eventually fallen out of favor. The review revealed that HHD is not only as effective as in-center hemodialysis but is also associated with better survival benefits over the latter. Several studies have found it to be significantly cost-effective compared to in-center hemodialysis. Newer types of HHD machines make it easier for the patients or their family/caregivers to administer it safely and effectively at home and while traveling. They have regenerated interest in HHD and the Medicare administration in the USA has already decided to make use of it at a more frequent rate.

Based on the evidence in the available literature, HHD is cost-effective when compared to in-center hemodialysis in terms of survival benefits, quality of life (QoL) of patients, and monetary savings. Newer portable bedside dialysis machines provide better safety and have simplified the procedure of hemodialysis, making HHD more acceptable to patients and caregivers. We believe HHD should be the preferred modality of treatment instead of in-center hemodialysis, and that applies to UAE too.

Introduction

Kidney disease is defined as an abnormality of the kidney structure or function with huge implications for the health of the affected individual. Chronic kidney disease (CKD) denotes various structural or functional disorders of the kidney present at least for three months, with variability in their clinical presentation, severity, and rate of progression. The concept of CKD was developed based on the recognition that disordered kidney function progresses from less severe to more severe disability at different rates of progression, which if detected early and intervened to slow down the rate of progression, would help in maintaining better health for longer periods for the patients as well as saving expenditure overall [ 1 ].

The number of CKD patients is increasing worldwide and CKD is currently the most significant contributor to morbidity and mortality from non-communicable diseases. It is a highly prevalent condition that accounts for a substantial proportion of the disease burden globally. The prevalence of CKD in the global population is about one out of 11 persons (9.1%). Its prevalence has not declined over the past 27 years as compared to the burden of many other important non-communicable diseases [ 2 ]. Among patients with CKDs of varying severity, those who suffer from the most severe ones cannot sustain their life and health without a treatment that involves substituting the function of the kidney. Such patients are called end-stage renal disease (ESRD) or end-stage renal failure (ESRF) patients, and, the treatments supporting their life by substituting the function of the kidney are called renal replacement therapies (RRTs). The number of kidney disease patients in general and those who require RRTs are increasing worldwide. Treatment modalities available for ESRD patients are kidney transplants and dialytic therapies. Both modalities are costly therapies, dialytic therapies being costlier than kidney transplants. The number of patients on dialytic treatment is much larger than those undergoing kidney transplants. It is because of the limited number of organs (kidneys) available for transplant and also because many patients are not medically or psychologically fit to undergo transplant surgery. Treatment costs for ESRD patients rose after the 1960s with the advent of dialytic renal replacement techniques, which improved the survival rate of those patients and required the long-term application of those life-saving costly treatments [ 3 ]. Dialytic therapies are of two types: peritoneal dialysis (PD) and hemodialysis (HD). Hemodialysis, which is more prevalent worldwide, could be administered either at home or in-center. While different modalities of PD for ESRD patients are carried out at home, hemodialysis at present is largely carried out at hospitals or specialized centers. Dialysis at home can be performed by the patients themselves or family/caregivers, or it could be nurse-assisted. All these forms of dialysis therapies, being costly and recurrent, put a large burden on the health systems globally, which often lead to the unavailability of these methods at times and in some places. Apart from the patient itself, it also affects the life of the family members involved in the care of the patient, leading to a decline in their quality of life (QoL), loss of their employment time, and their earnings. Thus, from both an individual and societal standpoint, even a small reduction in the cost of these services may have a marked impact in the long run.

Liyanage et al. found in their most liberal estimate that among the 2.6 million patients who received RRTs worldwide in the year 2010, only around 50% had actually required it. They observed a shortage of renal replacement services in many countries, resulting in the possible premature death of around 2.28 million adults from a lack of access to this treatment in 2010. They projected that the requirement would double by the year 2030. By their estimate, the number of patients receiving RRT worldwide in 2021 would be approaching 3.8 million [ 4 ]. On a similar note, Anand et al. estimated in their study that in 2010, there were at least 1.2 million premature deaths among diabetes and elevated blood pressure patients due to a lack of access to RRT and as many as 3.2 million premature deaths due to all causes of ESRD [ 5 ].

The current prevalence of CKD in the USA is around 15% with ESRD cases increasing at an average of 2.5% annually since 1996 [ 6 ]. This increase in the incidence and prevalence of ESRD patients is complicated by the increasing proportions of elderly patients and patients with multiple comorbidities among them. Currently, about half of the ESRD patients have diabetes and a majority of them have cardiovascular diseases [ 7 ]. An increasing proportion of elderly patients, frail patients, patients with diabetes, and patients with complex coexisting conditions, many of them not fully ambulatory and find the frequent travel to the dialysis center difficult, have been using hemodialysis. Such patients are less capable of self-care and unable to perform complicated procedures like dialysis. For such patients "nurse-assisted home dialysis program" is a very promising alternative [ 8 ].

Home hemodialysis (HHD), among the different types of RRTs, is not a new concept. Charles Kirby, a cardiac surgeon, in his presidential address to the American Society for Artificial Internal Organs (ASAIO) in 1961 talked about HHD as follows: "Perhaps what we need is a home dialysis unit to be placed by the patient's bedside so that he can plug himself in for eight hours once or twice a week" [ 9 ].

If we examine the history of the home and in-center dialysis, we find that both had been developed almost simultaneously as per the requirement of patient care. The technology of dialysis for saving the life of kidney failure patients was introduced for community use in 1962 when the Seattle Artificial Kidney Center was set up by Scribner and James Haviland [ 10 ]. It was followed in 1963 by the development of a miniature single-patient version of the machine by Babb, a professor of nuclear engineering at the University of Washington, and his team, which was intended for unattended HHD for a young girl patient named Caroline. Subsequently, it began to be used for HHD. Based on the experience during those years, thrice-weekly dialysis was established as a widely practiced and accepted standard [ 11 , 12 , 13 , 14 , 15 ].

As early as 1965, Hampers and Merrill from Boston reported about the successful use of HHD in four young male patients for more than a year in the Annals of Internal Medicine. They reported that the patients had welcomed the sense of independence associated with HHD, and they had achieved a full work week because the dialysis was usually done in the evenings; moreover, they felt that they were participating in their care and hence had some control over their future. The flexibility of the dialysis schedule to suit the individual's social, business, or medical needs was a great advantage over the rigid schedule of any hospital program [ 16 ].

In the USA, when the Medicare Act provided people with coverage for RRT in 1972, 40% of patients were undergoing HHD, which declined to only 0.7% by 2003 [ 17 ]. In his review article, CR Blagg has discussed the reasons for the change in the practice trend and stressed why HHD should be the preferred treatment of choice [ 18 ]. As per the estimates of Medicare stakeholders in 2016, 50% of ESRD patients in the USA could be eligible for HHD while the utilization was merely around 4%. Medicare has set a target of 25% utilization of HHD for ESRD patients, which has not been attained yet [ 19 ].

HHD as a treatment practice for kidney failure patients is useful and superior in many ways but is currently the least practiced method. There has been a renewed interest in the HHD among different stakeholders involved in the care of patients requiring RRTs. In light of this renewed interest in HHD and the high cost of RRTs, an economic evaluation of this modality of therapy compared to the other modalities is required. The purpose of this study was to explore the utility of this treatment modality in the United Arab Emirates (UAE) in terms of cost-effectiveness. The research question was developed based on an inquiry from the health regulator of Abu Dhabi if home dialysis with a portable dialysis machine was cost-effective compared to in-center hemodialysis. The machine "DIMI" was chosen as a representative of several portable hemodialysis machines that have been developed recently and approved by health regulators of the USA and the European Council (EC). The methodology of the study is illustrated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram below (Figure ​ (Figure1 1 ).

Materials and methods

The research question developed was as follows: "Would HHD using a portable hemodialysis machine compared to in-center hemodialysis be cost-effective in the UAE?" This question was developed to find the evidence-based answer for a similar informal inquiry from the health authority of Abu Dhabi (UAE). The machine DIMI was selected as a representative of the standard type of newly developed portable bedside hemodialysis machine, which had the advantage over other machines to deliver all modalities of hemodialytic therapies including hemodiafiltration.

Since no similar studies had been performed in the past among patients in the UAE, to answer the study question, the PRISMA model of a systematic review of published literature was planned. A literature search of PubMed, Science of Web, and Cochrane Review databases was performed using the keywords "Home Hemodialysis", "Home-based Dialysis", "Cost-effectiveness of Dialysis", "Cost-effectiveness of renal replacement therapy", "cost of hemodialysis" etc. The literature search was restricted to the period from 1st January 1960 to 31st January 2021.  Title and abstract screening of 127 non-duplicate citations were performed to apply the criteria for relevance; 57 citations that were not related to hemodialysis, those related to dialysis but not related to chronic hemodialysis, and those related to acute kidney Injury only were excluded. Forty-four full text and 26 abstracts among the 70 citations were selected and studied, and 18 articles out of those 70 were found to be contributory toward evidence synthesis in quantitative and qualitative terms (Figure 1 ). Apart from an analysis of the selected articles, we also engaged in a thorough review of the literature on the topic [ 1 - 52 ].

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Nine studies provided evidence that HHD was effective or superior to in-center hemodialysis in terms of survival benefits. There was only one study done in that UAE, which was not comparative but had analyzed the QOL issues of patients who had received NxStage-based nurse-assisted HHD (NAHHD). Eight papers that consisted of reviews, analyses, or studies had addressed the cost-effectiveness of HHD as compared to in-center hemodialysis and/or other modalities of RRTs (Table ​ (Table1 1 ).

*All forms of HHD (conventional, long, frequent, or long/frequent sessions) vs. all forms of PDs (continuous ambulatory or automated PDs); **17% at 28 years

HHD: home hemodialysis; PD: peritoneal dialysis

Is home hemodialysis effective?

The effectiveness of HHD has to be established before its cost-effectiveness with in-center hemodialysis can be compared. The effectiveness of HHD can be examined by different parameters such as survival and mortality, QoL, cardiovascular outcomes, effect on mineral bone disease, and side effects, etc. For brevity, we restricted this study to survival and mortality, and, QoL, which also encompassed the cardiovascular component. 

Whenever survival benefit among dialysis patients of different modalities has to be compared, the dose of dialysis delivered has to be considered so that the outcome is measured on an equivalent basis. The famous HEMO study published in 1982 looked into the effects of the dose of dialysis and the level of the flux of the dialyzer membrane on mortality and morbidity among patients undergoing maintenance hemodialysis. The dosage defined the quantity of dialysis while the flux of the membrane decided the size of the molecules that could be removed during dialysis; a higher flux membrane could remove larger molecules. The randomized HEMO study involving 1,846 patients undergoing hemodialysis thrice weekly found that there was no major benefit from a higher dialysis dose than that recommended by contemporary US guidelines, which entailed the urea-reduction ratio of 66.3 ±2.5%, the single-pool Kt/V 1.32 ±0.09, and the equilibrated Kt/V 1.16 ±0.08, or the use of a high-flux membrane [ 20 ].

Because the same dose of dialysis could be delivered over variable durations, the effect of the duration of dialysis in addition to dialysis dose was studied by various researchers later on. Different studies have confirmed that dialysis duration of fewer than four hours a session three times a week was associated with an increased mortality rate of up to 42%. Longer duration of dialysis with same dialysis dose was associated with improved cardiac status and chance of survival benefit [ 21 , 22 , 23 ].

Having set the dosage of dialysis, the survival benefit could be compared between different modalities of hemodialysis. Several studies have compared survival benefits between in-center hemodialysis and HHD. Weinhandl et al. compared mortality in HHD patients who initiated RRT with the NxStage System One (similar to DIMI) from 2005 to 2007 with matched thrice-weekly in-center hemodialysis patients. The study found a weak beneficial effect of HHD on the risk of death. They found that the risk of death for daily HHD patients was 13% and 18% lower in intention-to-treat and as-treated analyses, respectively [ 24 ]. Nadeau-Fredette et al. found that HHD was associated with better patient survival than treatment with PD (five-year survival: 85% vs. 44%, respectively; log-rank: p<0.001) [ 25 ]. This study showed excellent survival results. Several other studies have found that HHD provided the best patient survival rates [ 26 , 27 , 28 , 29 , 30 ]. Woods et al. used data from the United States Renal Data System (USRDS) and found that the unadjusted relative risk of death among HHD patients compared with center dialysis patients was 0.37 (p<0.01). If controlled for age, race, gender, and cause of renal failure, the relative risk was 0.58 (p=0.02), and with additional adjustment for comorbid conditions, it was 0.57 (p=0.03) [ 31 ]. These studies support the hypothesis that HHD is not only effective but it also has significant survival benefits over the in-center dialysis.

Is home hemodialysis cost-effective?

RRT is one of the costliest therapies. Approximately 1% of the health budget is accounted for by patients of dialysis and transplant. Even a small change in cost per procedure would result in a huge change in the cost borne by the system.

An economic evaluation of the treatment is a difficult subject in which a comparative analysis of the alternative courses of action is performed. It deals with both the inputs and outputs, which can be described as the costs and consequences of alternative courses of action. It can be done as cost-effectiveness analyses (CEAs) where a single common effect that may differ in magnitude between the alternative programs is compared. A variant of cost-effectiveness is cost-utility analysis in which, for the consequences, a generic measure of health gain such as quality-adjusted life-year (QALY) is measured. A cost-benefit analysis estimates the additional health benefits of a given intervention and the additional cost benefits associated with achieving those health benefits [ 32 , 33 ].

The outcomes of cost-effectiveness evaluation are presented as the "incremental cost-effectiveness ratio" (ICER), a ratio of the difference in costs between two interventions, divided by the difference in their respective outcomes [ 34 ]. Several researchers have tried to explore the economics of the RRTs. Most of them have reported their findings in terms of cost-saving.

Walker et al. performed a systemic review of the cost-effectiveness of contemporary HHD modalities compared with facility hemodialysis. They concluded that HHD modalities including nocturnal and daily HHD were cost-effective or cost-saving compared with facility-based hemodialysis because of lower staff costs, and better health outcomes for survival and QoL. They observed that expanding the proportion of hemodialysis patients managed at home was likely to produce cost savings [ 34 ].

As early as 1968, Klarman et al. noted a $7,400 difference in the cost per life-year gained in favor of HHD as compared to conventional hemodialysis. It was $11,600 vs. $4,200 for conventional hemodialysis and HHD, respectively. The cost-effectiveness ratio (the difference in cost of HHD and conventional hemodialysis divided by the difference in their effect) was markedly in favor of HHD compared to conventional hemodialysis [ 35 ]. An annual cost of care difference of $21,000 ($51,252 for in-center hemodialysis vs. $29,961 for HHD; p<0.001) was noted by Lee et al. [ 36 ].

Ashton and Marshall explored the organization and financing of dialysis and kidney transplantation services in New Zealand. They noted that in New Zealand, there was optimum utilization of home dialysis compared to in-center dialysis. In New Zealand, 41% of patients were treated at hemodialysis units while 59% were treated at home: 45% home PD and 14% HHD (ANZDATA). Estimated costs (NZ$) for ESRD modalities in New Zealand during 2002-2004 were as follows: hospital hemodialysis: NZ$64,318 per patient per year; HHD: NZ$33,548 per patient per year. Most likely, the funding constraints encouraged the physicians and patients to choose higher utilization of HHD therapies, which kept the total expenditure per ESRD patient relatively low [ 37 ].

Mowatt et al. performed a comprehensive systemic review of effectiveness and cost-effectiveness, and economic evaluation of HHD vs. hospital or satellite unit hemodialysis for people with ESRF and found that HHD was less expensive than hospital hemodialysis. In their view, with an increasing number of ESRD patients, a corresponding increase in HHD offered an option for restricting increases in the RRT budget [ 38 ].

Croxson and Ashton performed an economic evaluation of continuous ambulatory peritoneal dialysis (CAPD), HHD, in-center hemodialysis, and transplantation using cost-effectiveness analysis to evaluate the cost per life-year saved. They noted that the value of the cost per life-year saved, expressed in 1988 $NZ, was 35,270 for in-center dialysis, 28,175 for HHD, and 26,390 for CAPD [ 39 ].

Krahn et al., from the Toronto Health Economics and Technology Assessment Collaborative, used the Canadian Organ Replacement Register (CORR) to study 15,240 patients aged 18-105 years who initiated chronic dialysis over a period of nine years between 1st April 2006 to 31 March 2014 in the Canadian province of Ontario, to evaluate the costs and the survival data. The highest five-year unadjusted survival was for HHD patients (80%), followed by PD (52%), and it was lowest for facility hemodialysis (42%). The mean 30-day cost (as-treated) for patients receiving HHD was 64% lower than for facility hemodialysis patients [ 40 ].

In their study, Howard et al. used a multiple cohort Markov model to assess costs and health outcomes of RRT for new ESRD patients in Australia during 2005-2010. They concluded that switching new patients from hospital hemodialysis to HHD could save A$46.6 million by 2010 [ 41 ]. de Wit et al. studied the cost-effectiveness and cost-utility of dialysis and transplantation over a period of five years by using a Markov-chain model based on the actual Dutch ESRD program and found in-center hemodialysis to be the least cost-effective treatment. They concluded that in countries where in-center hemodialysis was the only or the major treatment option for ESRD patients, substitutive policies for home-based treatment like HHD or CAPD would have a substantial impact on the cost-effectiveness of ESRD treatment [ 42 ].

The number of CKD patients and ESRD patients is increasing globally. Kidney transplant has several limitations, especially that of availability, which will result in an increasing number of ESRD patients on different dialytic treatments including hemodialysis. Despite the findings that HHD is associated with the best patient survival rates, a better quality of life, better chances of rehabilitation and ability to work, better control of blood pressure, etc., its use has declined gradually over time. In fact, this trend seems quite unreasonable. In the USA, this was partly due to inadequate payments for HHD modality for the first five years of the Medicare system. It should be noteworthy that the practice pattern in the USA is considered a standard model to be followed in many other countries. Another reason for the decline was that many patients were considered unfit for self-care either by the physician or by the patients themselves. Once a patient attends in-center dialysis, he or she is likely to develop "learned helplessness" [ 43 ]. This learned-helplessness makes the patient depend more on hospitals and clinics, while ideally, the patients of chronic diseases like ESRD should have been involved in their own care [ 44 ]. To develop and maintain this required self-care, training and involvement from treating physicians and nurses to impart education are required. That requires a well-structured program. A successful HHD program is more than just a treatment modality. In fact, it is more a system than a treatment [ 45 ]. At present, the interest in HHD has re-emerged among different stockholders including the industry. As mentioned above, the Medicare administration in the USA in 2016 has estimated that 50% of ESRD patients in the USA could be eligible for home dialysis. Medicare plans to increase the acceptance of HHD and has set a target of 25% utilization of HHD for ESRD patients [ 19 ].

The dialysis medical industry has been actively engaged since 1991 to develop new hemodialysis machines more suitable for use at home in terms of portability and lesser requirement of space, simplification, and improved safety. Different hemodialysis machines developed and approved by health authorities for use as "home hemodialysis machines" are (1) The Baxter VIVIA Hemodialysis System (Baxter Healthcare Corporation, Deerfield, IL), (2) Fresenius Medical Care 2008K@Home Dialysis Machine (Fresenius Medical Care AG & Co., Bad Homburg, Germany), (3) NxStage System One (NxStage Medical, Inc., Lawrence, MA), (4) Quanta SelfCare+ (Quanta Dialysis Technologies, Alcester, UK), (5) Physidia S³ device (Physidia Medical Devices, Saint-Barthélemy-d'Anjou, France), and (6) DIMI, etc. [ 17 ].

The Baxter VIVIA hemodialysis system was designed to deliver high-dose hemodialysis, which could provide all types of hemodialysis at home. It provided reuse of the dialyzer and bloodlines employing heat disinfection and automatic prime and rinse-back. An integrated access disconnect system; an animated, patient-friendly, graphic user interface; wireless connectivity to the clinic; an integrated heparin pump; an integrated water treatment source; and online dialysate generation were the other cutting-edge technologies available with that system. The drawback was that it was not portable, and it lacked an integrated blood pressure monitor system. It was approved by EC in 2013 but unfortunately, Baxter withdrew it in 2016 [ 46 ]. The 2008K@Home machine by Fresenius was similarly withdrawn. It could also provide all types of hemodialysis. In addition to other features of VIVIA, it had an integrated blood pressure monitor, and dialysate concentration could also be varied. It lacked a reuse system and required larger space. It had "WetAlert", a wireless wetness monitor at the needle site, which would stop the blood pump if the alarm was activated. It had some drawbacks as well: the machine was not portable, required an external water treatment source, larger space, significant home remodeling, and higher initial setup cost. Dissimilar to these two machines and more similar to PD Cycler are the other machines: NxStage System One, Quanta SelfCare+, Physidia S³, and DIMI. These four machines are portable. These can be used during travel, do not require large space except for the storage of consumables. These have battery backup in case of power shutdown. These are similar in their function and simplify the connection of the patient to the machine. These machines use a disposable drop-in cartridge with blood and dialysate lines with a dialyzer attached. The last one in this group, DIMI, can be used to carry out PD or other diafiltration treatments like hemodiafiltration too.

As mentioned above, these machines use disposable drop-in cartridges with blood and dialysate lines with a dialyzer attached. NxStage System One has been used in the USA and UAE. In their report about their one-year experience with NAHHD by using the NxStage machine in bed for homebound and multi comorbid hemodialysis patients, Bernieh and Calaud from UAE confirmed its efficacy, good quality, and safety. It had a significant positive impact on the QoL and satisfaction of both patients and their families [ 47 , 48 ]. Komenda et al. has reported on the successful use of QuantaC+ [ 49 ]. DIMI has been reported to provide promising results by Di Liberato et al. [ 50 ].

HHD is both a treatment modality as well as a system. In the UAE, HHD has been provided since 2016. At present, there are two active service providers of home hemodialysis: NMC Provita International Medical Centre and Home Hemo Dialysis. Both service providers provide NAHHD. NMC Provita uses regular hemodialysis machines fixed at patients' homes while Home Hemo Dialysis uses NxStage System One. Efficacy of this system using a portable dialysis machine, e.g., DIMI in UAE, has already been reported [ 48 ]. There is no official exact estimate of the number of patients requiring RRT in the UAE. But observes in the field have suggested that the number is on the rise. SEHA Kidney Care, the largest provider of RRTs in Abu Dhabi, has reported that the total delivered hemodialysis sessions were over 77,314 on a thrice-weekly basis from the beginning of March till the end of August 2020 [ 51 ]. Based on this, we can estimate that a total of 1,074 patients were dialyzed regularly by SEHA Kidney Care. In addition, there are other providers like NMC Royal Hospital, Mediclininc Hospital, Ahalia Hospital, Burjeel Hospital, and Al Mazroui Medical Centre Day Surgery, etc. which are also providing hemodialysis. If we assume that the services provided by these operators amount to at least one-fifth of those by SEHA Kidney Care, the total number of patients would be around 1,300, which would amount to 590 patients per million people.

Since 2020-21, the world has been facing a severe healthcare crisis in the form of the coronavirus disease 2019 (COVID-19) pandemic, and HHD can provide increased benefits for dialysis patients in this situation.

Because the cost-effectiveness can be derived by parallelism, the tested effectiveness of NxStage System One would be applied to DIMI. DIMI-based therapy cannot be inferior or less cost-effective than NxStage System One-based therapies. Since the payment to the service provider is not differentiated based on the device used but by the service, and HHD is a cost-effective service with greater survival and QoL benefits, dialysis service rendered at home would be cost-effective. It would save (1) the expenditure on the part of the patient's family over traveling, and (2) the loss of work for relatives who would be required to assist the patients three times every week. In such a situation, the part of the earnings at the service provider end is transferred indirectly to the patients and their families who turn out to be the real beneficiaries. Compared to NxStage System One, DIMI can provide improved quality and cost-effectiveness in dialytic treatment because this machine can also carry out hemodiafiltration, which has been proven to be more advantageous than simple hemodialysis [ 52 ].

Conclusions

Based on the discussion above, it could be confirmed that any HHD service including that with DIMI would be cost-effective anywhere, including the UAE. NAHHD, which is the currently available service model of HHD, provides multiple benefits to the patients and their caregivers, and it should be actively promoted. The limitation of this study is that it derives its conclusion from parallelism since there is no head-to-head study available on the cost-effectiveness among the UAE dialysis population comparing HHD to in-center dialysis. A study in the future addressing this aspect would be interesting and would also provide more accurate data. There is a lack of data regarding the demographic characteristics of the on-dialysis population in the UAE. Hence, we do not know if the study population in the studies we included in our review were similar to the UAE dialysis population or not. Thus, this study also provides awareness about this information gap as well as possible areas of required research on this subject.

Acknowledgments

The research question was developed on the basis of an informal inquiry from the health regulatory authority in Abu Dhabi if home hemodialysis could be cost-effective in the United Arab Emirates and if different types of machines had any significance in that regard. The researcher has received travel and educational grant assistance from Fresenius, Amgen, and Roche in the past. There was no conflict of interest related to the manufacturer or supplier of the DIMI dialysis machine. The researcher did not receive any grant from any source for this work of research.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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Episode 1: Traveling While on Home Hemodialysis

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Vanessa: Hello and welcome to visits with Vanessa, a podcast where we speak with home hemodialysis patients and care partners about their experiences doing home dialysis. Today’s episode will focus on traveling with your portable NxStage system. Our topics will include things to consider before you travel, things to consider when you get to your location, as well as a few other tips to make it a great trip. I’m a dialysis patient for over 23 years, and I am also the senior manager of Advocacy and communications for Fresenius Medical Care. I’m excited to share my own personal journey and experiences with traveling. I have a great friend, patient advocate, and care partner, Dawn, who’s going to join me. Before I start, I do want to say that Dawn is a paid advocate for NxStage. Dawn, can you introduce yourself today?

Dawn: Absolutely my name is Dawn, and I am a care partner for my husband Jimmy. He has been a dialysis patient for 13 years and for about 7 and a half of those years we have done home hemodialysis and used the NxStage system.

Vanessa: That’s great, Dawn, thanks so much for joining us today. We have a lot to discuss, a lot of people don’t realize that you are able to travel with home hemodialysis and the NxStage system. That being said, we are dealing with COVID-19 and it’s important to take every precaution when you travel because you want to make sure that you’re traveling safely, right? So I know that I myself was fully vaccinated before I took any trip this past year, so I got both my shots. How about you Dawn?

Dawn: Oh absolutely, Jimmy and I were both vaccinated as soon as it was available to us.

Vanessa: Awesome, you also should always talk to your doctor and your health care team. The Pfizer vaccine is actually now FDA approved, so that’s a positive for patients that were waiting until that was approved. And it’s always important to to plan and take your time before planning any kind of a trip. So let’s get into it a little bit Dawn, first, let’s just start by how many trips do you think you and Jimmy have taken?

Dawn: You know, it’s funny that you say that because Jimmy and I were just discussing this last night and in the seven and a half years that he’s been doing home hemodialysis, I think we’ve taken about 17 trips.

Vanessa: Wow, that’s a lot of trips, but I’m still ahead of you, Dawn. I think I’ve taken 29 trips within the last five years. Definitely slowed down a little bit with COVID, but I’m happy to be traveling again. Just, making sure that everything is safe. But I’m sure we have a lot of listeners on here today that are probably thinking what do I even do when I take my first trip? How do I get started? What is it that I need to do? How much time do I need to plan? So I thought we could start with kind of dispelling some myths that people might have and discussing what is the first step. So, when you took your recent first trip, tell me a little bit about what’s the first thing that you do when you’re planning a trip.

Dawn: Well, the first thing we need to do is decide where we’re going and how we’re going to get there. Most of our trips have been by car and so we need to get a hold of our home dialysis nurse 60 days in advance to give them forewarning so that they know they can get all of our supplies ordered so we have them in the right amount of time. After that we have to make sure that we have the soft case reserved because like I said, we’re traveling in car. Now Vanessa, I know you travel by plane a lot. What do you do?

Vanessa: Yep, so because I am such an avid traveler, actually I have gone ahead and I have purchased my own soft case and hard case. So, on my last trip that I just did not even a week ago, it was by car and so I did put the machine in the soft case and I was able to put it into the car that way. And the trip before that that I did maybe two or three months ago, I used the hard case because I did travel by plane and when you travel by plane it is best advised to take a hard case. So I’m wondering Dawn because you talked a little bit about you asking your home nurse about the cases, is that because you are borrowing a case? Or why would that be?

Dawn: Yes, yes, I don’t own a case, so we always borrow from the center.

Vanessa: Yep, that makes sense. So now you’ve called your healthcare team. You’ve done the 60 days in advance because you want to make sure that everything is done in a timely manner and that your stuff has time to arrive and get there safely. Do you do anything in between your trip before you leave? Do you follow up with your healthcare team? Is there anything that we need to do as patients?

Dawn: Oh absolutely, we need to have a backup plan set up in case there’s an emergency, contact numbers. We need to pack extra supplies because God knows we could have an issue, that happens.

Vanessa: Yeah, it’s definitely happened before and and definitely a good idea to pack for extra supplies or ask for extra supplies to be delivered. And I also would say that it’s a good idea once you’ve spoken with your health care team and everything is all set up, you do get a confirmation email from NxStage saying that your travel order was put in. If you don’t receive an email then you need to call your healthcare team and ask if they submitted it or you need to reach out to NxStage and ask if there was a prescription submitted. So you want to look out for that email and it’s always good to just check in with your healthcare team and make sure that those pieces are being followed up upon is a great spot. So Dawn, now you’ve done all that, you’ve called, you’ve got your stuff all together. Tell me about your last trip, where did you and Jimmy end up going after you did your first steps?

Dawn: Oh, we had an amazing trip. We drove to North Carolina with another couple I might add that also does home dialysis and we rented a cabin in the mountains, and it was amazing. I don’t think we could have experienced the things we did with if Jimmy was still in-center.

Vanessa: That’s great and I do want to clarify for our listeners because I want to make sure that listeners know that there are options. So in your case you went in a car and I’m assuming that you brought your supplies with you. Am I correct to say that? Or how did that work?

Dawn: Yes, Vanessa, you are absolutely correct. It was just easier for us to load the machine into the car, load our supplies into the car and drive.

Vanessa: That’s great, now that is one option, right? So you can have some supplies that you have at home. You can load it into a car and off you go. The machine is portable. You can put boxes in and off you go. If you did not want to take those supplies in your car, you are able to work with your healthcare team for your travel prescription and the travel prescription will then be sent to your destination. And if you’re traveling by plane, which is what I did a couple of months ago, you can have your prescription sent to your destination and then you bring your ancillary supplies. Now listeners you might be thinking what are ancillary supplies, right? So ancillary supplies are your needles, your gauze, your band aids, your masks, all the other supplies that you would need in order to perform dialysis in another location. So when you’re traveling friends you can do your travel prescription and then you can bring your ancillary supplies on a plane. The key piece here is to pack the ancillary supplies in a separate bag. So one bag would have all your clothing for the trip and the 2nd bag would have all your ancillary supplies and that’s so that you can differentiate, because the Department of Transportation does have guidelines for traveling with a portable dialysis machine, you can refer to those guidelines and it does ask that your supplies be put in a separate bag. So that’s just an important note that we want to make sure that everybody knows. So Dawn, now you’re on this trip, you’re with your friends, and you know going on vacation is all about making memories, being there with friends and family, discovering new places and having fun. But, you also are with a dialysis patient, so you do need to do treatments and I’m wondering, you know how did you, how were you able to manage dialysis as well as be on the go and vacation with your friends?

Dawn: The Nice part about it, Vanessa, is that depending on what we had planned for the day that determined when we were going to do dialysis. Now, if we decided we were going to go out on the lake, you know, then we would do dialysis in the evening if we were going to travel then we would do dialysis in the morning. We made it work for us, so we didn’t miss anything.

Vanessa: Yeah, I relate to that. I basically would look at my schedule and I would say well, what am I doing tomorrow, right? And so knowing what we usually know, pretty much what we’re going to be doing the next day, are we going to the beach? Are we going out to a dinner? And I could move my dialysis treatments based upon my schedule and so if we were getting up early and going to the beach well then I’m going to dialyze you know that evening when we get back. If we were just kind of going to hang around the house and maybe go out later in the day, then I would dialyze in the morning. And it’s important to note that you can change your schedule and make it work for you. You don’t have to be on the same schedule as long as you’re following your prescription. So Dawn as much as we love vacationing and we love the experience, we have a bunch of listeners here that are probably thinking well what are some tips that I should do when I’m traveling? What if there are challenges? What if things arise? So what tips would you give? And then we can talk a little bit about challenges. But what tips would you give to our listeners today when you’re planning a trip?

Dawn: I would say the number one tip is to be prepared and to be prepared you need to communicate with your team. Communicate with NxStage. Communicate about all of your supplies. Make sure that you have everything you need. Check it and re-check it.

Vanessa: I would agree with that, and when challenges do arise, you want to make sure because you’ve had that communication with your health care team that there is a backup plan in place and that backup plan may include many of the following: It might be that you go to a local clinic if that’s what you need. It might be that they ship you a supply if that’s what you need, right? Remember that as dialysis patients, home patients, we’re doing more frequent treatments, so that is definitely a plus for us. And if and so challenges arise, you always fall back on your training. And I’m thinking a little bit Dawn about a story that you were telling me about when you and Jimmy traveled, because we know it’s not all unicorns and rainbows. Can you share with the listeners?

Dawn: Oh absolutely, you know it was an amazing trip. We made awesome memories with great friends, but the day we went out on the pontoon, it was hot and humid, and Jimmy didn’t hydrate as much as he probably should have. And we had a little bit of blood pressure issues that day, and with the training that we had, I was so confident that I could handle the situation not just with the machine, but the treatment itself, and I knew exactly what I needed to do, and then communicated that with his nurse, spoke to NxStage, and got everything set up. Our last day of vacation, our car broke down and we were 900 miles away from home. We have no more dialysis supplies and so I got in touch with our home nurse, I got in touch with NxStage, had a plan in action, all set in case we needed it but we were able to purchase a new vehicle and get home, and he didn’t miss a beat.

Vanessa: That’s great and a lot of that is the communication that you have. I know some of our listeners, you know might be thinking of a couple of questions, so one they might say well, how far in advance do I need to plan my trip? And so that is 60 days. So you want to make sure that you’re working with your care team at least 60 days in advance, and they’re going to work with the customer service team to be able to put in your prescription. And then the other question that I think we get a lot is there a charge for travel? Is there a charge for travel? and so patients that are wondering this, this is going to depend based upon your own personal prescription and insurance that you might have. And so I would recommend that if you want to know the answer to that question, you speak with your healthcare team and you see if this is something that does apply to you or does not apply to you. Lastly, Dawn going back to some of our questions here. So what advice would you give to a patient? What is the last tip that you would give to a patient that is ready to take their first trip?

Dawn: I would say that it is so important to communicate with your team. And yes, the first time you do it, it’s scary. It is scary, but you know what? It is so possible. And if you communicate with your team and you are prepared, you take all the steps that you need to for your trip. You are going to make the most amazing memories because home hemodialysis has given us so much freedom.

Vanessa: I agree with you Dawn, and I’m going to add a couple of things so I would say you know we talked about the first thing you do is you work with your family to figure out where you’re going. If you don’t have a case, you’re going to find out if you can borrow a case and they will put in a travel prescription, your nurse will put in a travel prescription. When you’re going to pack, it’s important to have a checklist. That way you know that you have all of your pieces in, so you’re going to pack all your travel pieces in with a checklist. You want to make sure that you’re planning ahead of time that you have a backup plan should you need it. Hopefully you would not need it, and most importantly, you want to make sure that you’re having fun. And lastly, and this is maybe an an overstep that I do, is if I have bags that are going to be traveling to a family’s house, I always have them arrive a couple of days in advance so I can make sure that they’re there and then I have my family member take a picture of it just because I like to visually see that everything’s there, and that, I think if you do those steps, I think that really helps for a safe and comfortable trip. So to our listeners, if you have any questions, and want to learn more about traveling with NxStage systems, please visit www.nxstage.com. To learn more about home hemodialysis please call one of our patient consultants at 1-888-200-6456. Our consultants are either current or former patients or care partners like you Dawn, that can help get information to learn more about home hemodialysis. It’s important to note that not all patients may experience these benefits. With that, Dawn, thank you so much for joining us today. It was invaluable to hear all about your traveling experiences.

Dawn: Thank you so much for having me, Vanessa.

Vanessa: Oh, thank you and for everyone, thank you for joining. I look forward to our next episode with visits with Vanessa. Thank you.

*Patient Advocates are compensated for their time.

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  Risk and Responsibility

Patients should review the following information carefully and discuss it with their doctors to decide whether home hemodialysis with NxStage systems is right for them.

Users should weigh the risks and benefits of performing home hemodialysis with NxStage systems.

• Medical staff will not be present to respond to health emergencies that might happen during home treatments, including, among other things, dizziness, nausea, low blood pressure, and fluid or blood leaks.
• Users may not experience the reported benefits of home, more frequent, or nocturnal hemodialysis with the NxStage systems.
• The NxStage systems require a prescription for use.

  Users will be responsible for all aspects of their hemodialysis treatment from start to finish.

• Medical staff will not be present to perform home treatments. Users will be responsible for, among other things, equipment setup, needle insertions, responding to and resolving system alarms, system tear-down after treatment, monitoring blood pressure, ensuring proper aseptic technique is followed, and following all the training material and instructions that nurses provide.

  Users will need additional resources to perform home hemodialysis.

• Users will need a trained care partner to be present during your treatment at home (unless their doctor prescribes “solo/independent” home hemodialysis, described below).
• Users must have a clean and safe environment for their home treatments.
• Users will need space in their home for boxes of supplies necessary to perform home hemodialysis with NxStage systems.

  Certain forms of home hemodialysis have additional risks.

• If a doctor prescribes home hemodialysis more than 3 times a week, vascular access is exposed to more frequent use which may lead to access related complications, including infection of the site. Doctors should evaluate the medical necessity of more frequent treatments and discuss the risks and benefits of more frequent therapy with users.
• If a doctor prescribes “solo/independent” home hemodialysis without a care partner during waking hours, risks of significant injury or death increase because no one is present to help users respond to health emergencies. If users experience needles coming out, blood loss, or very low blood pressure during solo/independent home hemodialysis, they may lose consciousness or become physically unable to correct the health emergency. Users will need additional ancillary devices and training to perform solo/independent home hemodialysis.
• If a doctor prescribes “nocturnal” home hemodialysis at night while the user and a care partner are sleeping, risks increase due to the length of treatment time and because therapy is performed while the user and a care partner are sleeping. These risks include, among other things, blood access disconnects and blood loss during sleep, blood clotting due to slower blood flow or increased treatment time or both, and delayed response to alarms when waking from sleep. A doctor may need to adjust users’ medications for nocturnal home hemodialysis, including, among other things, iron, Erythropoiesis-Stimulating Agents (ESA), insulin/oral hypoglycemics, anticoagulants, and phosphate binders.

Fresenius Medical Care has successfully completed its merger with NxStage Medical, Inc.

Fresenius medical care and nxstage have merged.

Fresenius Medical Care has successfully completed its merger with NxStage Medical Inc. By strengthening our vertically integrated dialysis business, the merger supports our initiative of driving growth in the core business with innovation, better clinical outcomes through Care Coordination and improving the patient experience. For information about NxStage products and services please continue to use this website. To learn more about Fresenius Medical Care and the merger, visit the links provided.

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