Is the cost of the new home dialysis techniques still advantageous compared to in-center hemodialysis? An Italian single center analysis and comparison with experiences from western countries.

Introduction: Potential advantages of home dialysis remained a questionable issue. Three main factors have to be considered: the progressive reduction in the cost of consumables for in-Center hemodialysis (IC-HD), the widespread use of incremental Peritoneal Dialysis (PD), and the renewed interest in home hemodialysis (H-HD) in the pandemic era. Registries data on prevalence of dialysis modalities generally report widespread underemployment of home dialysis despite PD and H-HD could potentially provide clinical benefits, improve quality of life, and contrast the diffusion of new infection among immunocompromised patients. Methods: We examined the economic impact of home dialysis by comparing the direct and indirect costs of PD (53 patients), H-HD (21 patients) and IC-HD (180 patients) in a single hospital of North-west Italy. In order to achieve comparable weekly costs, the average weekly frequency of dialysis sessions based on the dialysis modality was calculated, the cost of individual sessions per patient per week normalized, and the monthly and yearly costs were derived. Results: As expected, PD resulted the least expensive procedure (€ 23,314.79 per patient per year), but, notably, H-HD has a lower average cost than IC-HD (€ 35,535.00 vs. € 40,798.98). A cost analysis of the different dialysis procedures confirms the lower cost of PD, especially continuous ambulatory PD, compared to any extracorporeal technique. Discussion: Among the hemodialysis techniques, home bicarbonate HD showed the lowest costs, while the weekly cost of Frequent Home Hemodialysis was found to be comparable to In-Center Bicarbonate Hemodialysis.

Do central venous catheters have advantages over arteriovenous fistulas or grafts?

Central venous accesses have become an integral component of vascular access procedures for hemodialysis. Although the DOQI guidelines recommend that less than 10% of chronic hemodialysis patients should be maintained on catheters, in some countries higher prevalences are reported, as in the United States and the United Kingdom (18% and 24%, respectively, according to the DOPPS). The native arteriovenous fistulas are still the best suited accesses for hemodialysis. However, this option is impractical in many situations, so that several justifiable reasons exist for protracted dialysis catheter use; these include the catheter as a bridge angioaccess device, while the patient is awaiting living-related kidney donor transplantation or maturation of an autologous fistula or graft or, increasingly, as the permanent vascular access for patients with unsuitable vascular anatomy who have exhausted all other options. Moreover, the surgical creation of an AVF is felt to be impossible or at least seems to entail significant risks in situations of high output cardiac failure, myocardial ischaemic events and steal syndrome. In these cases, the dialysis access catheter brings considerable advantages, but it also carries tremendous drawbacks. In addition to the increased risk of luminal thrombosis, infection, unreliable blood flows, central venous stenosis, shorter use life and patient cosmetic concern, tunneled catheters are associated with an increased risk of death. Tunnellization, exit site protection, antibiotic-coated or antiseptic-impregnated hemodialysis catheters, antibiotic lock solutions could be helpful in preventing and treating catheter-related bacteremias. Moreover, the development of a subcutaneous port, that is durable, offers a high blood flow and is fully implantable subcutaneously, may become an alternative for chronic use. In our 10-year experience we implanted in our center over 450 central venous catheters with a satisfactory survival (86% at 1 year and 79% at 2 years for the subcutaneous port). In a matched comparison between Tesio twin catheters and Dialock ports (37 vs. 35, respectively), followed for a 2 year period, no significant differences emerged as regards bacteremia incidence, 0.58/1,000 catheter-days in the Tesio catheter group vs. 0.9/1000 catheter-days in the subcutaneous port group, p=0.12; thrombolytic agents needed, 4.5% vs 4.3% of dialysis sessions; or access failure with removal of the device, 8.1% vs 14.2%, p=0.4. The longer duration of antibiotic therapy in the Tesio group (24.6 vs 14.3 days, p=0.006) was due to the higher incidence of cutaneous infectious episodes (3.8 vs 0.16/1,000 catheter-days). In conclusion, although central venous catheter is the vascular access of last choice, in particular cases it can be a useful alternative, provided that strict protocols for nursing care and proper catheter management are implemented in every center.