How we did it: Quotidian Home Dialysis; Glendale, CA

An interview with Shawn Mehrabian, MS, Director of Operations

More than a decade of experience with home hemodialysis in Canada convinced Shawn Mehrabian that dialysis patients in the U.S. would benefit from more-frequent hemodialysis treatments. He joined forces with Dr. Raffi Minasian (an independent dialysis provider and dialysis facility Medical Director) and Sosie Mardirossian (a home hemodialysis training nurse) to form Quotidian Home Dialysis.

Building on experience

The Canadian partners decided to build on their years of experience by opening a dialysis center that focused on training and supporting patients for daily home hemodialysis treatments. "We are committed to improving quality of life for our dialysis patients, and we strongly believe that this can only be achieved through more-frequent dialysis," said Mehrabian.

The licensing process in Los Angeles County was slow (it took almost 17 months), but Quotidian began operation in Glendale, California, in late 2005—with the objective of providing home hemodialysis therapies.

By June of 2007, Quotidian Home Dialysis was managing more than two dozen patients on either short daily or slow nocturnal hemodialysis. Currently (July 2007), Quotidian Home Dialysis is in the process of opening a second center in La Habra, California.

Starting a new home program

Starting a new venture of any kind involves challenges, and that was certainly true for Quotidian Home Dialysis. "Our biggest challenge to the start of the program was the wait for licensing and certification which, at the time, had a long backlog," commented Mehrabian. "We also had to adapt to the U.S. health care system as there are differences between Canadian and U.S. delivery of care," he added.

Still, the Quotidian start-up was successful, although a bit slower than planned, because the team had key elements in place, including:

Experience with home modalities. Mehrabian thinks that renal professionals who have never worked with home hemodialysis will require education to gain an understanding of what is involved to make a home program work. "In our start-up, we did not use any consultants," Mehrabian said, "but rather relied on our experience to get the program off the ground."

"We have worked hard and have made this a smooth transition because we believe in the daily hemodialysis regimen and we know what (good) clinical outcomes await the patients." Mehrabian and the Quotidian team find it very rewarding "when patients who are receiving daily hemodialysis tell you that they feel they have gained their life back," he said.

Knowledgeable staff. "The success of our program is built on our team," said Mehrabian. In particular, dedicated nursing staff for training is essential. According to Mehrabian, one nurse educator can, depending on the patient(s) and equipment used, train two patients a month, and the same person can be responsible for up to 20 patients at home. "Sosie, our training nurse is just great," he said. "She can train any patient who can self-cannulate within a week," he claimed.

"Since the patient training, at least in our geographical area, is provided on a one-to-one basis, the challenge will be to have an educated nursing staff who can manage these programs. So, our biggest challenge now is to find more experienced nurses to expand our program." A well-trained PCT (Patient Care Technician) can also be involved with some aspects of patient training and this can assist in faster growth with more patients being trained.

Quotidian also provides round-the-clock nursing and technical phone support, and has a full time technologist on staff. Mehrabian believes that the need for technical support would be "very limited" if the program used only NxStage dialysis equipment.

Good training location. "Choosing a training location depends on several factors, including the nephrology referral base, and whether or not the training facility is freestanding or part of a dialysis unit/hospital," Mehrabian advised. "You will also have to decide on how big your service area is going to be because home patients will be spread out geographically and will require your services on an ongoing basis," he noted.

Offering options

Quotidian Home Dialysis tries to offer options that give patients the flexibility to manage their kidney failure without disrupting their lives. These options include:

Modalities. Quotidian trains patients to do either short daily home hemodialysis or slow nocturnal daily dialysis. "Offering different daily hemodialysis modalities helps us bring the benefits of more frequent dialysis to more patients," Mehrabian said.

Equipment. "We are one of the few centers that train patients on both the Fresenius 2008H/2008K delivery systems and the NxStage System One," said Mehrabian. "We believe that there is a place for both devices in helping patients get the dialysis they need."

Fresenius (FMC) offers a simple and a very reliable dialysis machine with years of experience in home hemodialysis services. And since its introduction, the NxStage machine has demonstrated an excellent track record, reliability, ease of use, and patient acceptance.

Cannulation procedures ("Sticking the access"). All patients with a fistula are trained on the buttonhole technique. "Patients will start to create their buttonhole during training," Mehrabian explained, "but we send them home with both blunt and sharp needles so that they can decide what works best for them at home."

Training schedules. Patients who are employed are given flexibility with regards to time and dates for training. Training time will vary according to the type of equipment used and the patient's learning ability.

Training home patients

Thorough training is a top priority at Quotidian Home Dialysis. Not only are patients trained to use both the FMC and NxStage machines, they are trained in the basic science of dialysis as well. "We provide a kind of 'Dialysis 101,' because we think that it really helps patients in the long run," Mehrabian explained.

He and the Quotidian staff find that the extra time spent in training more than pays off in the long run. "The patients are more comfortable at home, they can troubleshoot problems, and are less anxious about the whole process," he explained. He has found that patients who do not understand dialysis—who just know how to operate their machines—have more problems than patients who have a basic understanding of the process. "In the long run, well-trained patients need less handholding and have fewer problems," he added.

Overcoming patients' fears

The biggest concern patients have when considering daily hemodialysis is cannulation. Despite their fears, all our patients have quickly learned to cannulate themselves. Mehrabian believes the key to success is an experienced nurse who can make this part of the training process as smooth as possible.

Initially, many patients also fear dialyzing while they sleep. As a result, few Quotidian patients begin dialysis as nocturnal home patients. "It's difficult to convince patients to start dialysis at night," Mehrabian admitted. "They need to get comfortable with their equipment, cannulation, and their dialysis at home first. Once they are comfortable with their treatments, the transition from short daily to nocturnal becomes smooth and easy."

Mehrabian would like to see more U.S. patients choose slow nocturnal daily hemodialysis because he believes that "it is simply the best therapy available." In his experience, once patients feel the benefits of daily dialysis, they often request this transition on their own. "Our personal clinical experience has been that patients ask for more frequent treatments and eventually want to do nocturnal; NO patient on daily will skip 2 days in a row any more," he explained. Mehrabian reported that the demand for training is growing, and Quotidian Home Dialysis currently (July 2007) has a waiting list for its nocturnal home hemodialysis program.

Promoting slow, nocturnal treatments

"By any measure you choose, slow daily nocturnal hemodialysis offers the best therapy," Mehrabian said. He has noted that:

  • "Phosphate removal is twice as effective as conventional dialysis, with many patients even requiring additional phosphate in their diet. This allows most patients to stop using phosphate binders. Most patients have no dietary restrictions.
  • Sleep disorders, which are prevalent in the chronic hemodialysis population, are significantly improved. Sleep apnea, a common problem for ESRD patients, may be corrected.
  • Anemia, a common problem with ESRD patients, improves with an increase in hemoglobin and thus a reduction in EPO use.
  • High blood pressure is also a common problem for people with kidney disease (and made worse by fluid overload). The majority of patients on daily nocturnal hemodialysis no longer require blood pressure medication because of normalized fluid balance. This also leads to improved heart muscle function.
  • Patients have normalized albumins and an increase in nutritional status."

"With each new study/publication, additional areas of improvement in nocturnal dialysis become apparent," he added, "such as the recent study indicating cognitive improvement." He noted, "in our practice, we see a great improvement in our patient's quality of life compared to patients on conventional trice weekly dialysis."

Growth of home programs

It is important to educate patients about their choice of modality, including daily home hemodialysis. Once they have the basic information regarding daily therapies at home and its benefits, 30-45% of patients will choose daily home hemodialysis. However, "Our experience in both the U.S. and Canada has shown that currently with existing technology and practice about 10-15% of the total ESRD population can be trained for home hemodialysis. This in itself represents a large number of patients given the total ESRD population in the U.S." he said. Mehrabian believes this number could increase if home dialysis equipment could be made simpler and easier to use. "NxStage has taken an important step in that direction," he noted.

According to Mehrabian, daily nocturnal hemodialysis is the standard of care in Canada for patients seeking daily hemodialysis therapies. "A majority of home hemodialysis patients in Canada are on nocturnal, and the results are excellent," he claimed. At Quotidian, about one-third of the patients currently use slow nocturnal hemodialysis and Mehrabian hopes to make it one-half by the end of 2007.

"History is a poor predicator of future (growth)," Mehrabian claimed, "We know from our experience that daily home hemodialysis with 5-or-6-times-a-week therapy will dramatically improve the way dialysis has been practiced over the past three decades."

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