Vikram Aggarwal, MD, discusses how the Northwestern Medicine Home Hemodialysis program has expanded in response to the COVID-19 pandemic. Aggarwal describes the training program their team quickly activated, benefits of home hemodialysis, as well as a particularly complex case that required a rapid shift to home hemodialysis at the onset of the pandemic.
Related: Aggarwal shares details of a patient who survived three heart transplants, multiple near-fatal infections, and a failed kidney transplant and then found herself also having to confront COVID-19. "This is one of the most challenging cases of home dialysis training I have seen in my 15 years of practice," says Aggarwal. Read more.
Selected Podcast
Bringing Kidney Care Home: Evolution During COVID-19
Featured Speaker:
Vikram Aggarwal, MD
Vikram Aggarwal, MD is an Assistant Professor, Department of Nephrology & Hypertension. Transcription:
Bringing Kidney Care Home: Evolution During COVID-19
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I’m Melanie Cole and today, we’re discussing Home Hemodialysis Program at Northwestern Medicine and how it has expanded in response to the COVID-19 pandemic. Joining me is Dr. Vikram Aggarwal. He’s a Physician and a Nephrologist in the Division of Nephrology and Hypertension at Northwestern Medicine. Dr. Aggarwal, it’s a pleasure to have you with us today. Your team the Home Dialysis Program at Northwestern Medicine in March of 2019. Tell us about the program, how it came about and how it’s evolved since the onset of the pandemic.
Vikram Aggarwal, MD (Guest): Hi Melanie. Nice to talk to you. And my pleasure to talk more about Home Hemodialysis Program at Northwestern. So, we launched our Home Hemodialysis Program which was a brand new program in March of 2019. Before the start of the pandemic, we had successfully trained seven patients to do hemodialysis at their homes of which two had received kidney transplant and we had five patients who are doing home hemodialysis before the start of the pandemic. And for obvious reasons, as pandemic started in March of this year, patients were very anxious, patients doing dialysis in the centers were very anxious and their concerns that they will be exposed to the infection while traveling to the dialysis three times a week and exposed to the staff and other patients. So, we got more requests from patients who were about to start dialysis and those who were already doing dialysis in the center. During this time, we trained five patients to do home hemodialysis. So, in short, our census doubled and several of them were more anxious and also did not have much good education about the options that they had to do dialysis at home as this modality was quite new to them.
So, what we did was we offered them good education and then we started off at giving them a trial of home hemodialysis in our Home Dialysis Clinic which is unique that it only offers home dialysis which is peritoneal dialysis and home hemodialysis. So, in this program, the patients started in a single room to train with one nurse and one patient care technician and their care partners came, received education at the same time got hemodialysis and after two weeks; these patients, all of them were very confident that they would want to proceed and do this hemodialysis at home. So, we continued to train them for next two to four weeks and we did that successfully. And eventually, all of them are doing hemodialysis at their homes and have avoided travelling to the dialysis center during this COVID pandemic. And almost all of them are working now. So, they are avoiding infections and at the same time, maintaining their functional status.
Host: What a great program Dr. Aggarwal. So speak about the increased risk of severe symptoms and mortality for dialysis patients and specifically, how dialysis centers may not be set up for social distancing as a result of all of the equipment. Tell other providers why you feel it’s so important if they are considering setting up a home dialysis program; why you feel it’s so important and maybe even some of the challenges that you found while you were setting it up.
Dr. Aggarwal: So, the challenges have become more exaggerated during the COVID pandemic and for obvious reasons, the patients who have to do dialysis have to travel so they – three times a week or four times a week to the unit. In fact they have to take some means of transportation, go to the unit, be exposed to the staff and the other patients who are doing dialysis there. So, they are definitely much more exposed. And we have seen that, and it has been reported that a lot of these patients who go to hemodialysis because of their increased exposure, they are at more risk of getting COVID infection. In addition, there have been reports or publications showing that the fatality or death rate of the patients on dialysis with COVID was significantly higher compared to the other patients who are not on dialysis and had COVID.
So, definitely, this has challenged the lives of patients doing dialysis and of course, these are uncertain times and a lot like most of the organizations – the dialysis organizations are adopting to this new pandemic. And in that, the entire nephrology community has realized that home dialysis option would definitely be a safer option and a lot of the larger programs have started to adapt and focus more on home dialysis which includes home hemodialysis and peritoneal dialysis. And the advantages of home hemodialysis over in-center dialysis are two-fold. One is the unique medical advantage of being able to do more frequent and more longer hemodialysis sessions and that is definitely more helpful for patients to have a better cardiovascular and heart health and related hospitalizations.
So, in short, home hemodialysis is able to maintain a better heart health for patients who have heart conditions or even those who are at risk of having worsening of heart conditions while they are doing hemodialysis. In addition, studies have shown that patients who do more frequent home hemodialysis have better blood pressure control and definite reduction in the number of medications. They also need less dietary restrictions in terms of fluids and phosphate in their diet. These patients have a unique advantage that they’ll recover fast or their functional status gets better after one session of dialysis. Patients who are doing more frequent dialysis at home, have less symptoms of fatigue and cramps after a dialysis session which otherwise limits their functional status.
It also improves their sleep quality and definitely overall leads to a better quality of life compared to those who go to the center for three times a week hemodialysis. In addition, the second-fold advantage is that this ability to do hemodialysis at home allows them to go to work and travel.
Host: Dr. Aggarwal, as we’re talking about home dialysis, for patients that are considering it, for providers that would like to advise and counsel their patients about this option; is it difficult for patients in the home as far as equipment and cleanliness and sanitary conditions and learning how to use some of these things when maybe they’ve never done anything like this before. What would you like other providers to know about counseling their patients on the technology required and what they need to know?
Dr. Aggarwal: That’s a very good question. I think it’s a very vital question is since you are adopting to a newer care model, it is very important to have a very thorough buy-in of the patients and try to know from them that what are their goals for life. So, it has to be a very well-informed decision making before we venture into training these people for home hemodialysis. So, in that, I think the key is thorough education and understanding of the patient that what will be their responsibility. So, what we have done, the unique thing that we have done is we have organized not only one but at least three education sessions for the patient and their care partners which are very important in this whole doing dialysis at home. Is for them to come into the unit or we also arrange Telemedicine education sessions so that they could understand and make more informed decisions.
So, I think that’s the key is provide upfront all the information that they need to make a confident decision. And after that, once that platform is created, that the patients are willing to proceed with this on challenging training initially, they are willing to work with you to make this successful. So, I think the key here is good education and then having confidence and having a great staff or champion nurses to train these patients and make it successful for them.
Host: Well as long as we’re talking about the success of the program, based on that success, Dr. Aggarwal, during the pandemic, do you feel home hemodialysis could play a larger role in kidney care in the future just as we’re seeing how creative the healthcare industry has had to be during this pandemic and how Televisits have really come into play and I don’t see them going anywhere anytime soon; do you think that home dialysis will play a larger role in kidney care in the future?
Dr. Aggarwal: Absolutely. So, even before we were facing this pandemic, it was in July 2019, there was presidential executive order which launched the Advancing American Kidney Health Initiative establishing a goal of 80% of patients with end-stage renal disease treated with either home dialysis or kidney transplant by 2025. So, these policy changes and in addition to needs for social distancing which were created by this pandemic, home dialysis options will be certainly more popular, mode of doing dialysis. This has been a great learning experience here at Northwestern and now with the experience generated by committed nurses as well as committed patients; we have a model which is going to only get better. And create more inspiration for other patients and health systems to adopt this at their respective places.
Host: And Doctor, since we all like to hear outcomes, and patient success stories; you recently had a very complex case of home hemodialysis training. Tell us a little bit more about the challenges and successes with this particular patient.
Dr. Aggarwal: Absolutely. The story we are talking about is of one of our patients who actually is currently doing peritoneal dialysis, which is more of home dialysis, but her story is very inspirational. She is a young girl who had her third heart transplant and a kidney transplant in October 2019 of which the kidney transplant failed as soon as it was placed. She was unfortunately hospitalized for almost four months after the transplant because of multiple infections and as she was immunocompromised. After which, she was in rehabilitation facility and then upon discharge, she faced the challenges of doing in-center dialysis. She was also bound to a wheelchair because of the long hospitalization left to have both leg weakness. So, she was travelling to the dialysis unit three to four times a week and had a very complex heart situation which needed more fluid to be removed and often do five times a week dialysis.
So, she had met me in the hospital during our long hospitalization and gone over thorough education about home dialysis options. And as soon as she left rehab and go to in-center dialysis, and that even COVID had started, she contacted me, and she preferred doing peritoneal dialysis. The challenge with peritoneal dialysis is to begin with, it is not a very robust therapy and while people are transitioning from in-center dialysis to peritoneal dialysis, they have to travel not only to in-center dialysis but also come to the peritoneal dialysis program to train. So, which kind of means that they have to be travelling six days out of a week to transition to peritoneal dialysis and continue hemodialysis.
Well at Northwestern, we had a unique advantage that we offer hemodialysis and peritoneal dialysis at the one location so, we used our home hemodialysis machines to provide the needed hemodialysis while she was transitioning and learning peritoneal dialysis. So, this hybrid of therapies that we provided her at one location at the home dialysis center at Northwestern, was really a major advantage to her and within six weeks, she was able to train and do peritoneal dialysis by herself at home. And it has been about five months that she’s been at home and doing peritoneal dialysis and is not travelling anymore. Being immunocompromised, she is very much high risk to get COVID infection but the entire efforts by the team committed nurses and the patient herself, has lead her to being safe at home during this challenging time.
Host: Well that certainly is an inspirational story. Dr. Aggarwal as we wrap up, what advice do you have for your colleagues at other institutions who are interested in starting a home hemodialysis program at their institution and while you’re telling us that, tell us a little bit about your multidisciplinary approach and your team approach and really let them know why it’s so important that they refer to the experts at Northwestern Medicine.
Dr. Aggarwal: It is beyond my imagination that how Northwestern Home Dialysis Program has responded to these unique needs of the patients. And even how the patients have selected this home hemodialysis with complete confidence in our team. So, both patients and our team have gotten together to create this very successful model where we have trained 13 patients to do home hemodialysis and this has now become the largest academic home hemodialysis program in Chicagoland area. My advice to the programs is that the most important thing is to provide very robust education to the patients from very dedicated team which we have a unique advantage that we are able to provide real time and Telemedicine education to patients about peritoneal dialysis, home hemodialysis and that we follow up on these patients so that we support them with their decision making. Once the decision making is strong, and patients are on-board; I think the next challenge is to have champion nurses train them and that often is always successful. The major challenge in the newer programs is and we had it in the beginning was that often patients will drop out during the education period as they did not have very thorough education. So, I think thorough education in addition to having a strong champion team is the most important aspect which we’ve formed that group at Northwestern.
In addition, we have wonderful patient advocates who have lent their support to other people wanting to do home hemodialysis. So, in short, our multidisciplinary team which included patients, who are currently training, our nursing staff, our champion facility administrator, a Northwestern hospital itself and patient advocates who have done home hemodialysis before and have had kidney transplants. This whole team at Northwestern is a unique support to the patients who want to do home hemodialysis in the future and that builds a lot of confidence in not only the patients but the providers who want their patients to have advantage of home hemodialysis.
Host: What great points all. Dr. Aggarwal, thank you so much for coming on and sharing your expertise and telling us about the Home Hemodialysis Program at Northwestern Medicine. To refer your patient or for more information, please visit our website at www.nm.org/nephrology to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. For more updates on the latest medical advancements and breakthroughs please follow us on your social channels. I’m Melanie Cole.
Bringing Kidney Care Home: Evolution During COVID-19
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I’m Melanie Cole and today, we’re discussing Home Hemodialysis Program at Northwestern Medicine and how it has expanded in response to the COVID-19 pandemic. Joining me is Dr. Vikram Aggarwal. He’s a Physician and a Nephrologist in the Division of Nephrology and Hypertension at Northwestern Medicine. Dr. Aggarwal, it’s a pleasure to have you with us today. Your team the Home Dialysis Program at Northwestern Medicine in March of 2019. Tell us about the program, how it came about and how it’s evolved since the onset of the pandemic.
Vikram Aggarwal, MD (Guest): Hi Melanie. Nice to talk to you. And my pleasure to talk more about Home Hemodialysis Program at Northwestern. So, we launched our Home Hemodialysis Program which was a brand new program in March of 2019. Before the start of the pandemic, we had successfully trained seven patients to do hemodialysis at their homes of which two had received kidney transplant and we had five patients who are doing home hemodialysis before the start of the pandemic. And for obvious reasons, as pandemic started in March of this year, patients were very anxious, patients doing dialysis in the centers were very anxious and their concerns that they will be exposed to the infection while traveling to the dialysis three times a week and exposed to the staff and other patients. So, we got more requests from patients who were about to start dialysis and those who were already doing dialysis in the center. During this time, we trained five patients to do home hemodialysis. So, in short, our census doubled and several of them were more anxious and also did not have much good education about the options that they had to do dialysis at home as this modality was quite new to them.
So, what we did was we offered them good education and then we started off at giving them a trial of home hemodialysis in our Home Dialysis Clinic which is unique that it only offers home dialysis which is peritoneal dialysis and home hemodialysis. So, in this program, the patients started in a single room to train with one nurse and one patient care technician and their care partners came, received education at the same time got hemodialysis and after two weeks; these patients, all of them were very confident that they would want to proceed and do this hemodialysis at home. So, we continued to train them for next two to four weeks and we did that successfully. And eventually, all of them are doing hemodialysis at their homes and have avoided travelling to the dialysis center during this COVID pandemic. And almost all of them are working now. So, they are avoiding infections and at the same time, maintaining their functional status.
Host: What a great program Dr. Aggarwal. So speak about the increased risk of severe symptoms and mortality for dialysis patients and specifically, how dialysis centers may not be set up for social distancing as a result of all of the equipment. Tell other providers why you feel it’s so important if they are considering setting up a home dialysis program; why you feel it’s so important and maybe even some of the challenges that you found while you were setting it up.
Dr. Aggarwal: So, the challenges have become more exaggerated during the COVID pandemic and for obvious reasons, the patients who have to do dialysis have to travel so they – three times a week or four times a week to the unit. In fact they have to take some means of transportation, go to the unit, be exposed to the staff and the other patients who are doing dialysis there. So, they are definitely much more exposed. And we have seen that, and it has been reported that a lot of these patients who go to hemodialysis because of their increased exposure, they are at more risk of getting COVID infection. In addition, there have been reports or publications showing that the fatality or death rate of the patients on dialysis with COVID was significantly higher compared to the other patients who are not on dialysis and had COVID.
So, definitely, this has challenged the lives of patients doing dialysis and of course, these are uncertain times and a lot like most of the organizations – the dialysis organizations are adopting to this new pandemic. And in that, the entire nephrology community has realized that home dialysis option would definitely be a safer option and a lot of the larger programs have started to adapt and focus more on home dialysis which includes home hemodialysis and peritoneal dialysis. And the advantages of home hemodialysis over in-center dialysis are two-fold. One is the unique medical advantage of being able to do more frequent and more longer hemodialysis sessions and that is definitely more helpful for patients to have a better cardiovascular and heart health and related hospitalizations.
So, in short, home hemodialysis is able to maintain a better heart health for patients who have heart conditions or even those who are at risk of having worsening of heart conditions while they are doing hemodialysis. In addition, studies have shown that patients who do more frequent home hemodialysis have better blood pressure control and definite reduction in the number of medications. They also need less dietary restrictions in terms of fluids and phosphate in their diet. These patients have a unique advantage that they’ll recover fast or their functional status gets better after one session of dialysis. Patients who are doing more frequent dialysis at home, have less symptoms of fatigue and cramps after a dialysis session which otherwise limits their functional status.
It also improves their sleep quality and definitely overall leads to a better quality of life compared to those who go to the center for three times a week hemodialysis. In addition, the second-fold advantage is that this ability to do hemodialysis at home allows them to go to work and travel.
Host: Dr. Aggarwal, as we’re talking about home dialysis, for patients that are considering it, for providers that would like to advise and counsel their patients about this option; is it difficult for patients in the home as far as equipment and cleanliness and sanitary conditions and learning how to use some of these things when maybe they’ve never done anything like this before. What would you like other providers to know about counseling their patients on the technology required and what they need to know?
Dr. Aggarwal: That’s a very good question. I think it’s a very vital question is since you are adopting to a newer care model, it is very important to have a very thorough buy-in of the patients and try to know from them that what are their goals for life. So, it has to be a very well-informed decision making before we venture into training these people for home hemodialysis. So, in that, I think the key is thorough education and understanding of the patient that what will be their responsibility. So, what we have done, the unique thing that we have done is we have organized not only one but at least three education sessions for the patient and their care partners which are very important in this whole doing dialysis at home. Is for them to come into the unit or we also arrange Telemedicine education sessions so that they could understand and make more informed decisions.
So, I think that’s the key is provide upfront all the information that they need to make a confident decision. And after that, once that platform is created, that the patients are willing to proceed with this on challenging training initially, they are willing to work with you to make this successful. So, I think the key here is good education and then having confidence and having a great staff or champion nurses to train these patients and make it successful for them.
Host: Well as long as we’re talking about the success of the program, based on that success, Dr. Aggarwal, during the pandemic, do you feel home hemodialysis could play a larger role in kidney care in the future just as we’re seeing how creative the healthcare industry has had to be during this pandemic and how Televisits have really come into play and I don’t see them going anywhere anytime soon; do you think that home dialysis will play a larger role in kidney care in the future?
Dr. Aggarwal: Absolutely. So, even before we were facing this pandemic, it was in July 2019, there was presidential executive order which launched the Advancing American Kidney Health Initiative establishing a goal of 80% of patients with end-stage renal disease treated with either home dialysis or kidney transplant by 2025. So, these policy changes and in addition to needs for social distancing which were created by this pandemic, home dialysis options will be certainly more popular, mode of doing dialysis. This has been a great learning experience here at Northwestern and now with the experience generated by committed nurses as well as committed patients; we have a model which is going to only get better. And create more inspiration for other patients and health systems to adopt this at their respective places.
Host: And Doctor, since we all like to hear outcomes, and patient success stories; you recently had a very complex case of home hemodialysis training. Tell us a little bit more about the challenges and successes with this particular patient.
Dr. Aggarwal: Absolutely. The story we are talking about is of one of our patients who actually is currently doing peritoneal dialysis, which is more of home dialysis, but her story is very inspirational. She is a young girl who had her third heart transplant and a kidney transplant in October 2019 of which the kidney transplant failed as soon as it was placed. She was unfortunately hospitalized for almost four months after the transplant because of multiple infections and as she was immunocompromised. After which, she was in rehabilitation facility and then upon discharge, she faced the challenges of doing in-center dialysis. She was also bound to a wheelchair because of the long hospitalization left to have both leg weakness. So, she was travelling to the dialysis unit three to four times a week and had a very complex heart situation which needed more fluid to be removed and often do five times a week dialysis.
So, she had met me in the hospital during our long hospitalization and gone over thorough education about home dialysis options. And as soon as she left rehab and go to in-center dialysis, and that even COVID had started, she contacted me, and she preferred doing peritoneal dialysis. The challenge with peritoneal dialysis is to begin with, it is not a very robust therapy and while people are transitioning from in-center dialysis to peritoneal dialysis, they have to travel not only to in-center dialysis but also come to the peritoneal dialysis program to train. So, which kind of means that they have to be travelling six days out of a week to transition to peritoneal dialysis and continue hemodialysis.
Well at Northwestern, we had a unique advantage that we offer hemodialysis and peritoneal dialysis at the one location so, we used our home hemodialysis machines to provide the needed hemodialysis while she was transitioning and learning peritoneal dialysis. So, this hybrid of therapies that we provided her at one location at the home dialysis center at Northwestern, was really a major advantage to her and within six weeks, she was able to train and do peritoneal dialysis by herself at home. And it has been about five months that she’s been at home and doing peritoneal dialysis and is not travelling anymore. Being immunocompromised, she is very much high risk to get COVID infection but the entire efforts by the team committed nurses and the patient herself, has lead her to being safe at home during this challenging time.
Host: Well that certainly is an inspirational story. Dr. Aggarwal as we wrap up, what advice do you have for your colleagues at other institutions who are interested in starting a home hemodialysis program at their institution and while you’re telling us that, tell us a little bit about your multidisciplinary approach and your team approach and really let them know why it’s so important that they refer to the experts at Northwestern Medicine.
Dr. Aggarwal: It is beyond my imagination that how Northwestern Home Dialysis Program has responded to these unique needs of the patients. And even how the patients have selected this home hemodialysis with complete confidence in our team. So, both patients and our team have gotten together to create this very successful model where we have trained 13 patients to do home hemodialysis and this has now become the largest academic home hemodialysis program in Chicagoland area. My advice to the programs is that the most important thing is to provide very robust education to the patients from very dedicated team which we have a unique advantage that we are able to provide real time and Telemedicine education to patients about peritoneal dialysis, home hemodialysis and that we follow up on these patients so that we support them with their decision making. Once the decision making is strong, and patients are on-board; I think the next challenge is to have champion nurses train them and that often is always successful. The major challenge in the newer programs is and we had it in the beginning was that often patients will drop out during the education period as they did not have very thorough education. So, I think thorough education in addition to having a strong champion team is the most important aspect which we’ve formed that group at Northwestern.
In addition, we have wonderful patient advocates who have lent their support to other people wanting to do home hemodialysis. So, in short, our multidisciplinary team which included patients, who are currently training, our nursing staff, our champion facility administrator, a Northwestern hospital itself and patient advocates who have done home hemodialysis before and have had kidney transplants. This whole team at Northwestern is a unique support to the patients who want to do home hemodialysis in the future and that builds a lot of confidence in not only the patients but the providers who want their patients to have advantage of home hemodialysis.
Host: What great points all. Dr. Aggarwal, thank you so much for coming on and sharing your expertise and telling us about the Home Hemodialysis Program at Northwestern Medicine. To refer your patient or for more information, please visit our website at www.nm.org/nephrology to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. For more updates on the latest medical advancements and breakthroughs please follow us on your social channels. I’m Melanie Cole.